Every finding on record at Morningside Nursing and Rehabilitation Center

Based on record review and interviews, the facility did not ensure that residents are free of significant medication errors. This was identified for one (1) resident (Resident #157) during Resident Council Meeting. Specifically, Resident #157 did not receive Insulin Lispro (a fast-acting meal-time insulin) prior to meals in accordance with the physician's order. Furthermore, the omission of several doses and the failure to notify the medical doctor potentiated increased risk of hypoglycemic episodes. The findings include: The facility's policy titled, Diabetic Management, dated effective 05/2021, documented multiple procedures to manage residents with diabetes and to document such care. The procedure titled, Insulin Dependent Diabetic with Routine Insulin Orders and Sliding Scale, documented the responsible nurse performs finger stick and administers routine insulin as ordered. Additionally, the responsible nurse holds all rapid-acting medication if the resident will not consume the scheduled meal or snack and notify the medical doctor to obtain an order to hold the medication. The procedure titled, Emergency Diabetic Management, documented that physicians should be notified according to the parameters as specified with blood sugar testing orders. Additionally, it is the practice that any time there are hypo-or hyperglycemic reactions, the medical doctor is to be notified, and a repeat blood glucose is taken. The facility's policy titled, Hypoglycemia Protocol, dated effective 07/2014, documented that hypoglycemia is defined as a blood glucose result less than sixty (60) milligrams per deciliter. The policy stated that the protocol should not be used when residents' blood glucose is greater than sixty (60) milligrams per deciliter. Of the risk factors for hypoglycemia listed, insulin administration is included. The protocol includes that the physician should be consulted to determine if subsequent doses of insulin should be given or changed. Resident #157 was admitted with diagnoses including hypertension, diabetes mellitus, and seizure disorder.The Minimum Data Set, dated [DATE] documented Resident #157's cognition is moderately impaired.On 04/23/2026 at 10:31 AM during the Resident Council Meeting, Resident #157 stated that they are diabetic and receive insulin, but their blood sugar was not checked the day before prior to meals.The Physician's Order for Insulin Lispro initiated on 03/05/2025 instructed to inject four (4) units subcutaneously before meals for diabetes. Notify Medical Doctor if blood sugar is greater than four hundred (400) milligrams per deciliter. The order did not specify the blood sugar level hold parameter for concern of hypoglycemia. The Physician's Order for Insulin Lispro initiated on 04/09/2025 instructed to inject eight (8) units subcutaneously before meals for diabetes. Notify Medical Doctor if blood sugar is greater than four hundred (400) milligrams per deciliter. The order did not specify the blood sugar level hold parameter for concern of hypoglycemia. The Physician's Order for Insulin Lispro initiated on 04/24/2025 instructed to inject four (4) units subcutaneously before meals for diabetes. Notify Medical Doctor if blood sugar is greater than four hundred (400) milligrams per deciliter. The order did not specify the blood sugar level hold parameter for concern of hypoglycemia. 1.The Medication Administration Record revealed that Insulin Lispro was not administered for twenty-one (21) out of twenty-four (24) opportunities for the 6:30 AM scheduled dose from 04/01/2026 to 04/24/2026. Code four (4) indicating vitals outside of parameter was documented for one (1) scheduled dose administration opportunity. Code five (5) indicating hold/see nurse notes was documented for four (4) scheduled dose administration opportunities. Code nine (9) indicating other/see nurse notes was documented for sixteen (16) scheduled dose administration opportunities. The electronic medical record was reviewed. Medication administration nurse notes reviewed from 04/01/2026 to 04/24/2026 revealed fifteen (15) out of twenty-one (21) omitted 6:30 AM insulin lispro scheduled doses were documented to be omitted as the breakfast meal was not ready. Additionally, three (3) out of the twenty-one (21) omitted 6:30 AM insulin lispro scheduled doses were omitted without documented rationale. There was no documented evidence that a physician was notified for a hold order or that insulin lispro was administered prior to the breakfast meal. The electronic medical record documented the nurse note on 04/13/2026 at 7:18 AM to include resident noted with finger stick ninety-three (93) milligrams per deciliter. Scheduled insulin was held due to blood glucose level and concern for hypoglycemia. Resident remains alert and oriented, not in any form of distress. There was no documented evidence that a physician was notified or consulted. A physician progress note dated 04/09/2026 documented that resident noted with elevated blood glucose. The note also stated the insulin dose would be increased. The physician's note failed to document monitoring parameters. A monthly physician note dated 04/15/2026 failed to include documented parameters for finger stick monitoring. A physician progress note dated 04/24/2026 documented decrease Admelog (insulin lispro) to four (4) units subcutaneously before meals due to low blood sugar. Continue to monitor glucose trends. The physician's note failed to include monitoring parameters. During an interview on 04/28/2026 at 08:59 AM, Registered Nurse #9 stated they work 07:00PM to 07:00 AM. Registered Nurse #9 stated Resident #157 is to receive standing dose of insulin Lispro prior to meal service. Therefore, Resident #157's blood sugar is checked at 06:30AM daily and endorsed to next shift nurse for administration because breakfast is not served until 07:30AM.2.The Medication Administration Record revealed on 04/21/2026 and 04/22/2026 Resident #157 did not receive any doses of insulin lispro. Additionally, there was no documented evidence that blood sugar levels were obtained prior to meals on 04/22/2026. Code four (4) indicating vitals outside of parameter was documented for two (2) scheduled dose administration opportunities on 04/21/2026 when the documented blood glucose levels were 140 and 142. Code five (5) indicating hold/see nurse notes was documented for one (1) scheduled dose administration opportunity. Code nine (9) indicating other/see nurse notes was documented for three (3) scheduled dose administration opportunities. The electronic medical record was reviewed. Medication administration nurse notes on 04/21/2026 did not document any clinical rationale for omission of insulin doses or evidence that the medical doctor was notified. Medication administration nurse notes on 04/22/2026 documented omission of insulin lispro doses at 6:35 AM to be due to breakfast meal was not ready, at 10:52 AM medication was not on hand and on order, and at 5:45 PM medication was not on hand. There was no documented evidence that a physician was notified for a hold order or that insulin lispro was administered prior to the breakfast meal. Additionally, there was no documented evidence that a nurse supervisor or medical doctor was notified of the medication being out of stock. During an interview on 04/23/2026 at 09:24 AM, Registered Nurse #6 stated they worked from 7:00 AM to 7:00 PM on 04/22/2026. Registered Nurse #6 stated that Resident #157 had insulin ordered to be given prior to meal service along with blood sugar levels to be taken. Registered Nurse #6 stated Resident #157 was not given insulin Lispro prior to lunch and dinner because it was out of stock, but they believe they did check Resident #157's blood sugar levels. Registered Nurse #6 stated medications should have been ordered in advance, so they don't run out of the medications. Registered Nurse #6 stated they are supposed to notify the Nursing Supervisor and the Medical Doctor when a resident's medication is out of stock. However, Registered Nurse #6 could not recollect if the Nursing Supervisor and Medical Doctor were notified.During an interview on 04/23/2026 at 09:01AM, Registered Nurse #5 stated they worked from 7:00 PM to 7:00 AM on 04/22/2026. Registered Nurse #5 stated Resident #157's blood sugar was checked at 06:30 AM but they did not administer the insulin because the breakfast meal started at 7:30 AM. Resident #157's blood sugar level was endorsed for next shift nurse to administer the Insulin Lispro prior to serving the breakfast meal. Registered Nurse #5 was not aware that Insulin Lispro was out of stock on 04/22/2026 and could not explain why the blood sugar level was not documented in the electronic medical record.During an interview on 04/28/2026 at 11:05 AM, Registered Nurse #8, the Nursing Supervisor, stated they should be notified immediately when medication runs out. Registered Nurse #8 can check to see if the stock is available in their emergency supply of medications. If it is not available in the emergency stock, the Medical Doctor would be consulted for further instructions. Registered Nurse #8 stated they worked from 8:00 AM to 8:00 PM on 04/22/2026 but were never notified about Resident #157 and insulin being out of stock by Registered Nurse #6.During an interview on 04/28/2026 at 12:34 PM, the Director of Nursing stated they were recently made aware of the concerns related to Resident #157's insulin management and incident of omitted insulin on 04/22/2026. The Director of Nursing stated they have already started the plan of correction to address this issue. 10 New York Codes, Rules and Regulations 415.11(c)(3)(i)

Based on observation, record review, and interviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (1) resident (Resident #157) during Resident Council Meeting. Specifically, Resident #157's meal-time insulin order did not include specific hypoglycemia parameters; however, licensed nursing staff withheld scheduled meal-time insulin doses as ordered on multiple occasions despite parameters outlined by facility policy, without notifying or consulting the physician, and without documenting a clinical rationale. The findings include: The facility's policy titled, Diabetic Management, dated effective 05/2021, documented multiple procedures to manage residents with diabetes and to document such care. The procedure titled, Insulin Dependent Diabetic with Routine Insulin Orders and Sliding Scale, documented the responsible nurse performs finger stick and administers routine insulin as ordered. Additionally, the responsible nurse holds all rapid-acting medication if the resident will not consume the scheduled meal or snack and notify the medical doctor to obtain an order to hold the medication. The procedure titled, Emergency Diabetic Management, documented that physicians should be notified according to the parameters as specified with blood sugar testing orders. Additionally, it is the practice that any time there are hypo-or hyperglycemic reactions, the medical doctor is to be notified, and a repeat blood glucose is taken. The facility's policy titled, Hypoglycemia Protocol, dated effective 07/2014, documented that hypoglycemia is defined as a blood glucose result less than sixty (60) milligrams per deciliter. The policy stated that the protocol should not be used when residents' blood glucose is greater than sixty (60) milligrams per deciliter. Of the risk factors for hypoglycemia listed, insulin administration is included. The protocol includes that the physician should be consulted to determine if subsequent doses of insulin should be given or changed. Resident #157 was admitted to the facility with diagnoses including hypertension, diabetes mellitus and seizure disorder.The Minimum Data Set, dated [DATE] documented Resident #157's cognition is moderately impaired, and they received insulin injections daily. The Physician's Order for Insulin Lispro initiated on 03/05/2025 instructed to inject four (4) units subcutaneously before meals for diabetes. Notify Medical Doctor if blood sugar is greater than four hundred (400) milligrams per deciliter. The order did not specify the blood sugar level hold parameter for concern of hypoglycemia. The Physician's Order for Insulin Lispro initiated on 04/09/2025 instructed to inject eight (8) units subcutaneously before meals for diabetes. Notify Medical Doctor if blood sugar is greater than four hundred (400) milligrams per deciliter. The order did not specify the blood sugar level hold parameter for concern of hypoglycemia. The Physician's Order for Insulin Lispro initiated on 04/24/2025 instructed to inject four (4) units subcutaneously before meals for diabetes. Notify Medical Doctor if blood sugar is greater than four hundred (400) milligrams per deciliter. The order did not specify the blood sugar level hold parameter for concern of hypoglycemia. The Medication Administration Record revealed Insulin Lispro was not administered for thirty-six (33) out of seventy-two (72) opportunities from 04/01/2026 to 04/24/2026. The blood glucose readings at the time of omitted doses ranged from sixty-four (64) milligrams per deciliter to two hundred and two (202) milligrams per deciliter. The electronic medical record was reviewed for entries of nurse notes for clinical rationale of omission of insulin lispro administration. From 04/01/2026 to 04/24/2026, code four (4) indicating vitals outside of parameter was documented for eleven (11) administration opportunities. There was no documented evidence that blood sugar levels for Resident #157 were less than sixty (60) milligrams per deciliter or more than three hundred (300) milligrams per deciliter for any insulin lispro administration time from 04/01/2026 to 04/24/2026. There was no documented evidence that a physician was notified of any blood sugar level out of parameter or for any concern to withhold insulin lispro administration. During an interview on 04/27/2026 at 11:16 AM, Registered Nurse #1 stated they work from 07:00 AM to 07:00 PM. Registered Nurse #1 stated Resident #157 has rapid-acting insulin prior to meals with blood glucose monitoring. Registered Nurse #1 stated they are responsible for checking blood glucose and administering insulin Lispro for lunch at 12:15 PM, as lunch service is at 12:30 PM, and for dinner at 05:15 PM, as dinner service is at 05:30 PM. Registered Nurse #1 admitted the order does not indicate parameters to hold the insulin Lispro order. However, Registered Nurse #1 stated if Resident #157's blood glucose is less than 140 milligrams per deciliter, they withheld the medication to prevent hypoglycemic episodes. Registered Nurse #1 stated they did not know that Resident #157's insulin Lispro order at 06:30 AM was not being carried out by the night shift nurse. Registered Nurse #1 stated they were not informed by the night shift nurse that Resident #157's insulin Lispro was withheld due to breakfast timing.During an interview on 04/28/2026 at 11:05 AM, Registered Nurse #8, the Nursing Supervisor, stated Resident #157 is to receive insulin Lispro with glucose monitoring prior to meals at 06:30 AM, 11:30 AM and 04:30 PM. The night shift nurse is responsible for checking the blood sugar, documenting it in the medication administration record, and endorsing it to next shift nurse that the sugar was taken. Day shift nurses will give insulin prior to breakfast but withhold if blood glucose level is below 70 milligrams per deciliter. Registered Nurse #8 stated they were not aware that Resident #157 did not receive insulin on multiple occasions without consulting with the Medical Doctor.During an interview on 04/27/2026 at 12:35PM, the Medical Doctor was interviewed over the phone and stated they could not recall nurses relating that insulin Lispro was withheld for Resident #157. Medical Doctor stated they are in the facility very often, so they are reviewing Resident #157s blood glucose trends and adjusting as needed.During an interview on 04/28/2026 at 12:34 PM, the Director of Nursing stated they were recently made aware of the concerns related to Resident #157's insulin management and incident of omitted insulin on 04/22/2026. The Director of Nursing stated they have already started the plan of correction to address this issue. 10 New York Codes, Rules and Regulations 415.12

Based on observation, record review, and interviews, the facility did not ensure that it promoted and facilitated resident self-determination by supporting resident choice. Specifically, residents were not provided with showers twice a week per their bathing preference. This was evident for two (2) of three (3) residents (Resident #10 and Resident #108) reviewed for Choices out of a total of 38 sampled residents.The findings include: The facility's policy and procedure titled, Showers, dated effective 08/2020, documented each resident is to have a minimum of two baths or showers each week including shampoos. Unit nurses are responsible for monitoring the provision of resident showers on the assigned days, interviewing residents to determine the reason for any shower refusal, and making necessary adjustments or referrals. 1.Resident #108 has an active diagnoses including end stage renal disease, hemiplegia and cataract. The Annual Minimum Data Set assessment dated [DATE] documented Resident #108 was cognitively intact, required partial assistance for showering or bathing, and had not rejected care. The Annual Minimum Data Set also documented that it was somewhat important for Resident #108 to choose between a tub bath, shower, bed bath, or sponge bath. On 04/21/2026 at 10:33 AM, Resident #108 was interviewed and stated that they go to dialysis on Mondays, Wednesdays and Fridays. Resident #108 further stated that on the days that they return from dialysis they are too tired to receive showers and so they refuse it. Resident #108 stated that they had informed a nurse on the unit to switch their shower days to Tuesdays and Saturdays, instead of Wednesdays and Saturdays, as they were too tired on dialysis days to receive a shower. Resident #108 further stated that they have not been getting regular showers and that staff have offered various excuses as to why shower days cannot be changed. On 04/24/2026 10:36 AM, in a subsequent interview, Resident #108 stated that they were not offered showers on Saturday. Resident #108 stated that if they were offered showers, they would take one to freshen up and be clean. Resident #108 further stated that they do not prefer bed baths over showers, but it is easier for staff to provide them with bed baths as showers involve too much work for the staff including using the Hoyer lift to transfer Resident #108 for the shower. A care plan initiated for the resident has activities of daily living: self-care performance deficit related to diagnosis of end stage renal disease on hemodialysis, diabetes mellitus, anemia, history of right hemiplegia, cataract and other comorbidities was initiated on 01/24/2025. The care plan documented Resident #108 required partial/moderate assistance for showering and bathing self. The facility interventions included washing Resident #108's skin and hair with [NAME]-Shampoo/Body. The care plan did not document Resident 108's bathing preferences. There was no documented evidence in the nursing progress notes, behavioral notes or in the nursing episodic behavioral forms regarding Resident #108's refusal of showers for the month of March 2026 and April 2026. The Resident Kardex (a report containing resident care instructions that Certified Nursing Assistants must provide) as of 04/22/2026 documented Resident #108's shower schedule to be on Wednesdays and Saturdays from 3:00 PM to 11:00 PM and as needed. The Documentation Survey Report from 04/01/2026 to 04/22/2026 documented Resident #108 received a bed bath on 04/01/2026, 04/04/2026, 04/11/2026, 04/15/2026, 04/18/2026 and 04/22/2026 during the 3:00 PM to 11:00 PM shift. The Documentation Survey Report from 03/01/2026-03/31/2026 documented that Resident #108 received a bed bath on 03/04/2026, refused bed bath and shower on 03/11/2026, received a bed bath on 03/14/2026, was not applicable for bed bath or shower on 03/22/2026, and refused shower and bed bath on 03/28/2026 during the 3:00 PM to 11:00 PM shift. On 04/24/2026 at 10:47 AM, Registered Nurse #4 was interviewed and stated that Resident #108 goes to dialysis on Mondays, Wednesdays and Fridays. Shower days are scheduled in the evening from 3:00 PM to 11:00 PM on Wednesdays and Saturdays. Registered Nurse #4 further stated that they were not aware that Resident #108 had refused showers. On 04/24/2026 at 10:55 AM, Registered Nurse Supervisor #2 was interviewed and stated that they have not heard from staff or any residents regarding any shower related issues or concerns. On 04/24/2026 at 10:57 AM, Certified Nursing Assistant #13 was interviewed and stated that Resident #108 is supposed to get showers twice weekly in the evenings and had previously mentioned concerns regarding the shower schedule a couple of weeks ago. Certified Nursing Assistant #13 further stated that Resident #108 had stated to them that the scheduled time of their showers fall on dialysis days and they are too tired after dialysis to take a shower. Certified Nursing Assistant #13 stated that Resident #108 stated they would like different shower days that do not fall on dialysis days. Certified Nursing Assistant #13 stated that they had informed the nurse/nurse manager regarding this issue at that time but cannot recall the name of who they had reported it to. On 04/24/2026 at 3:01 PM, Certified Nursing Assistant #16 was interviewed and stated that they work the evening shift from 3:00 PM to 11:00 PM. When Resident #108 is assigned to them, they will usually give Resident #108 a bed bath because they refuse showers. On 04/24/2026 at 3:41 PM, Certified Nursing Assistant #14 was interviewed and stated that Resident #108 will frequently refuse showers and bed baths but could not provide the reason as to why the resident refused showers and bed baths. Certified Nursing Assistant #14 stated Resident #108 had not mentioned anything regarding dialysis and their preferred shower schedule. Certified Nursing Assistant #14 stated that Resident #108 refused both shower and bed bath on 04/18/2026, but they had accidentally documented that Resident #108 received a bed bath. Certified Nursing Assistant #14 stated that they had previously reported Resident #108's refusal of showers to the nurse on the unit. On 04/27/2026 at 10:40 AM, in a subsequent interview, Registered Nurse #4 stated that it is important for residents to have regular showers for hygiene purposes. If residents voiced concerns about showers, the staff would encourage them to take a shower. Despite encouragement, if residents still refused, the staff would offer bed bath. Residents' families would also be notified that there are refusals of showers, and a care plan would be made. If residents refuse showers, the Certified Nursing Assistant should tell the nurse on the unit who would make a note in the system. Then, it is escalated to the nursing supervisor and the doctor. The family would also be informed. There should also be an episodic note stating that they refused. Registered Nurse #4 further stated that if a resident voiced concern about the shower days, then the care plan would be updated to accommodate the change in schedule. On 04/27/2026 at 3:31 PM, Certified Nursing Assistant #15 was interviewed and stated that there are days when Resident #108 refuses showers and prefers bed baths. The Certified Nursing Assistant #15 stated that as per their knowledge, Resident #108's shower schedule has always been on Tuesdays and Saturdays. They were not aware of any different shower days. Certified Nursing Assistant #15 further stated that Resident #108 has told them that they are too tired after dialysis to get showers and so the preferred days were Tuesdays and Saturdays. Resident #108 must be transferred via Hoyer lift for showers. Certified Nursing Assistant #15 further stated that when Resident #108 refused showers, they would report it to the charge nurse who said they would document it in the system. Certified Nursing Assistant #15 further stated that they cannot recall all the names of the charge nurses to whom they reported Resident #108's shower refusals, as different ones are assigned to the unit. Certified Nursing Assistant #15 further stated that they have reported it to Registered Nurse #10 who is currently on the unit. On 04/27/2026 at 3:38 PM, Registered Nurse #10 was interviewed and stated that it's important for residents to receive showers for dignity and health reasons. Registered Nurse #10 stated that Resident #108 has not mentioned anything to them regarding showers or the shower schedule. Registered Nurse #10 further stated that they were not aware Resident #108 has refused showers, and staff has not informed them regarding Resident #108's refusal of showers. On 04/27/2026 at 3:53 PM, Unit Manager #1 was interviewed and stated that if a resident refused to shower, the Certified Nursing Assistant must report it to the nurse. The nurse will reapproach the resident and if there is still a refusal, the doctor and family will be notified. A progress note will be entered, and the resident will be reapproached at a later date. The nurse will document it in the system, and the care plan will be updated. If there is no documentation on resident refusal of showers, it is a problem as it evidences a lack of communication between the Certified Nursing Assistant and the Nurse. Unit Manager #1 further stated that they were not previously made aware of Resident #108's shower schedule concerns. On 04/28/2026 at 10:03 AM, Charge Nurse #1 was interviewed and stated that they work from 7:00 PM to 7:00 AM on most weekends, Friday to Sunday. They have been on the unit since October 2025. Charge Nurse #1 stated that there have been times where Resident #108 refused showers in the past and bed baths had been offered. If residents refuse care, then it is important to document residents' refusals. Charge Nurse #1 stated that when Resident #108 refused shower, they had documented it in the behavior note or in the episodic behavior form. Charge Nurse #1 further stated that they were not aware Resident #108 had an issue with shower days colliding with dialysis days. On 04/28/2026 at 10:05 AM, The Director of Nursing was interviewed and stated that providing residents with regular showers is important for dignity and resident comfort. If a resident refuses a shower, the Certified Nursing Assistant must notify the nurse so that they can get another staff to re-offer it to the resident. The reason as to why the resident is refusing should also be found and addressed by the facility if it is something the facility can address. The resident's family should also be notified, and shower refusal should be documented in the system. A progress note would be written and care plan updated to reflect the resident's refusal of showers. It is important to document resident's refusal of showers; otherwise, there is no evidence to prove that the resident was offered showers. The Director of Nursing stated that they were aware that Resident #108 refused showers in the past but did not know the reason showers were refused. 2.Resident #10 was admitted to the facility with diagnoses including end stage renal disease, hyperlipidemia, and diabetes mellitus. The admission Minimum Data Set, dated [DATE] documented that it is very important for Resident #10 to choose between a tub bath, shower or sponge bath. The Quarterly Minimum Data Set, dated [DATE] documented Resident #10 is cognitively intact and dependent on staff for shower. Resident #10 did not reject care. During an interview with Resident #10 on 04/22/2026 at 11:02 AM, Resident #10 stated they were not receiving showers as per biweekly schedule. The care plan for Refusal, initiated 03/03/2026, documented Resident #10 refused shower on 11/11/2025. Interventions included allowing resident to verbalize cares/concerns regarding care needed, encourage family in plan, establish routine and reinforce the importance of care needed. The Certified Nursing Assistant Instruction for Bathing, effective from 03/31/2026 to 04/22/2026 documented Resident #10's shower schedule is Tuesdays and Fridays during 3:00 PM to 11:00 PM shift and as needed. The Certified Nursing Assistant Documentation Record for Bathing, from 03/31/2026 to 04/22/2026 had no documented evidence Resident #10 received showers. The record documented Resident #10 received a bed bath on 03/31/2026, 04/03/2026, 04/07/2026, 04/10/2026, 04/17/2026, 04/21/2026 during 3:00 PM to 11:00 PM shift. No bed bath or shower was provided on 04/14/2026. The Nursing Notes dated from 03/31/2026 to 04/22/2026 revealed no documented evidence that Resident #10 received or refused showers. During an interview on 04/24/2026 at 09:37 AM, Certified Nursing Assistant #3 stated a resident's shower schedule can be found in their electronic system and on the shower schedule sheet at the nursing station. Certified Nursing Assistant #3 stated Resident #10 was given bed bath on 03/31/2026, 04/10/2026 because shower was refused. Certified Nursing Assistant #3 further stated that the nurse should be informed when any care is refused but they could not recall if the nurse was notified on those days. During an interview on 04/24/2026 at 09:43 AM, Certified Nursing Assistant #5 stated it was about 10:30 PM when Certified Nursing Assistant #5 realized shower was not done in accordance with schedule shown in the plan of care record for Resident #10. Certified Nursing Assistant #5 documented that shower was not applicable because it was too late to provide the shower. Certified Nursing Assistant #5 could not recall if unit nurse was notified of the shower not being done on that day. During an interview on 04/24/2026 at 10:40 AM, Certified Nursing Assistant #4 stated Resident #10 has shower scheduled every Wednesday and Saturday during 07:00 AM to 03:00 PM shift. Resident #10 has refused shower in the past so Certified Nursing Assistant #4 has been providing bed baths on their shower days. Certified Nursing Assistant #4 stated that on 04/22/2026, Resident #10 could not be showered or provided with bed bath because Resident #10 went out on an appointment and did not return until after 11:00 AM. During an interview on 04/24/2026 at 10:53 AM, Licensed Practical Nurse #1 stated Certified Nursing Assistants are responsible for providing shower/bed bath in accordance with residents' bathing schedules. Licensed Practical Nurse #1 stated that Certified Nursing Assistants are giving bed baths to Resident #10 because the resident refused showers which have been documented in the task completion record. Licensed Practical Nurse #1 stated Certified Nursing Assistants should notify Licensed Practical Nuse #1 when both shower/bed bath are refused by the resident. Licensed Practical Nurse #1 stated they probably were not notified because Resident #10 had been receiving bed baths on bathing days. During an interview on 04/24/2026 at 11:21 AM, Registered Nurse #7 stated they were not aware that Resident #10 was receiving bed baths in lieu of showers. Registered Nurse #7 stated Certified Nursing Assistants are responsible for informing unit nurses when residents refuse showers. During an interview on 04/28/2026 at 12:14 PM, Director of Nursing stated all residents are provided with showers twice a week and as needed, and schedules are determined by the room number. Certified nursing assistants are responsible for offering residents the shower in accordance with the shower schedule. When shower is refused, certified nursing assistants should notify unit nurses who will then interview the residents to determine the reason for refusal. Any adjustments will be implemented in the residents' care plans for staff to follow. During an interview on 04/28/2025 at 12:43PM, the Administrator stated Resident #10 had documented refused showers in the past in their care plan which are reviewed/discussed in interdisciplinary meeting every quarter. However, the Administrator could not provide documented evidence that this behavior of shower refusal is currently ongoing for Resident #10. 10 New York Codes, Rules and Regulations 415.5(b)(1-3)

Based on observations, record review, and staff interviews, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. Specifically, a comprehensive care plan for a resident's hearing impairments was not developed and implemented. This was evident for one (1) resident (Resident #170) reviewed for Vision/Hearing out of a total of 38 sampled residents.The findings include: The facility policy and procedure titled, Care Planning Process, dated effective 07/2022, stated that the facility shall have a care planning process that is a person-centered which includes: integrating assessment findings in care planning, developing an interdisciplinary care plan, regularly reviewing and revising the care plan, as well as providing and documenting care. Resident #170 was admitted to the facility with diagnoses that included anemia, hypertension, and asthma (chronic obstructive pulmonary disease or chronic lung disease). The Annual Minimum Data Set, dated [DATE] documented Resident #170 has intact cognitive status, requires setup or clean-up assistance of staff for eating, oral and personal hygiene, upper body dressing, and requires partial/moderate assistance of staff for most other activities of daily living. There is no documented evidence of Speech Language Pathology and Audiology Services provided to Resident #170. On 04/21/2026 at 9:56 AM, Resident #170 was interviewed and stated that they have problems hearing well and they need to turn up the television very high to be able to hear a little bit now; Resident #170 stated that they have hearing aids but lost them, reported it to staff, but have not received replacement hearing aids. Physician's order dated 01/06/2026 documented, Consult: 'ENT:' Ear Nose Throat Consult for decreased hearing. Progress note, Medical, dated 04/15/2026 at 3:46 PM, documented that Resident #170 reports acute inability to hear in right ear, confirmed on assessment. Will consult Ear Nose Throat . acute Right ear hearing loss .Active Diagnosis and Treatment Plan: Right ear hearing loss . The electronic medical record for Resident #170 was reviewed. There is no documented evidence that a comprehensive care plan was developed or implemented for the care being provided for Resident #170's hearing impairment/hearing aids. On 04/24/2026 at 12:18 PM, Certified Nursing Assistant #1 was interviewed and stated that they have taken care of Resident #170 when assigned to the unit. Certified Nursing Assistant #1 stated that Resident #170 has problems hearing during care and has always complained of having difficulty hearing well. Certified Nursing Assistant #1 stated that they were not sure if Resident #170 has hearing aids and did not know if Resident #170 lost their hearing aids. On 04/24/2026 at 2:13 PM, Registered Nurse #1 was interviewed and stated that every time they go to Resident #170's room, Resident #170 would complain that it is difficult to hear very well since their hearing aids were missing. Registered Nurse #1 admitted that despite the resident's complaints, they didn't know Resident #170 had hearing aids. Registered Nurse #1 further stated that residents' hearing aids are usually documented on Point Click under Certified Nursing Assistant Accountability Records (CNAAR). However, Registered Nurse #1 admitted they don't know how to check that documentation. Registered Nurse #1 stated that when Resident #170 reported difficulty hearing due to the missing hearing aids few days ago, it was reported to the Assistant Director of Nursing who ordered an ear consult. Registered Nurse #1 further stated that to initiate comprehensive care plan or episodic care plan, the nurse on the floor was supposed to complete an SBAR (Situation, Background, Appearance, Request or Recommendation) for the team to initiate a comprehensive care plan. Registered Nurse #1 could not explain why there was no comprehensive care plan initiated for Resident #170's hearing problem. On 04/24/2026 at 2:34 PM, the Supervisor, Registered Nurse #2, was interviewed and stated that based on chart review, Resident #170 was not admitted with hearing aids. Registered Nurse #2 stated that when Resident #170 verbalized having difficulty hearing, an Ear Consult was ordered on 04/15/2026. Resident #170 was seen by the consultant and earwax was removed from resident's ears. Registered Nurse #2 stated that they were not aware that Resident #170 did not have a care plan in place for hearing problems as they were not on the unit all the time and because Resident #170 was not noted with hearing problem upon admission. On 04/24/2026 at 2:42 PM, the Assistant Director of Nursing was interviewed and stated that they are not aware that Resident #170 has hearing aids; the Assistant Director of Nursing stated that an Ear-Nose-Throat (ENT) consultation was ordered on 04/15/2026 when Resident #170 complained of difficulty hearing. The resident was seen by the consultant on 04/22/2026, ear wax was reportedly removed, and documentation revealed that resident's ear examination was within normal limits with no new order given. The Assistant Director of Nursing stated that they did not realize that there was no comprehensive care plan documented for Resident #170's hearing impairment yet. The Assistant Director of Nursing was unable to state why there was no care plan initiated for Resident #170's hearing impairment. On 04/27/2026 at 10:56 AM, The Director of Nursing was interviewed and stated that if there are acute changes of condition for residents, the nurses on the unit should check, address the problem, and initiate the care plan to ensure that the problem is resolved. The Director of Nursing stated that they believe that Resident #170's care plan for hearing problems should have been initiated immediately when Resident #170 complained of hearing problems. The Director of Nursing stated that they were surprised that a care plan was not in place to address Resident #170's hearing impairments. 10 New York Code, Rules and Regulations 415.11(c)(1)

Based on observation, record review, and interviews during an abbreviated survey (2704295), the facility did not ensure that each resident received adequate supervision to prevent accidents. This was evident for one (1) out of three (3) residents (Resident #1) sampled for accidents. Resident #1 had severely impaired cognition, was assessed as high risk for falls, and had history of multiple falls. Specifically, Resident #1 experienced recurring falls on five occasions between 11/21/2025 and 01/05/2026. Despite these incidents, preventative supervision of Resident #1 was not documented in the care plan until after the fall on 01/05/2026 at 1:50 AM. There were no injuries noted in Resident #1's medical record because of the falls.The findings include:A facility's policy and procedure titled, Fall Prevention Program dated 06/2024, documented it is the policy of the facility to identify the fall risk of all residents and outline interdisciplinary interventions to prevent falls. The licensed nurse will screen all residents for all fall risk upon admission, quarterly, annually, and significant change and after each fall. A care plan for the prevention of falls will reflect interventions for fall prevention and injury reduction. Fall and Injury Prevention Plan documented collaboration, with interdisciplinary team members for implementation and evaluation of the individualized comprehensive care plan. Discuss safety risk levels in team conferences and identify specific strategies for fall prevention in the care plan. A facility's policy and procedure titled, Visual Checks dated 07/2013, documented it is the facility's policy that all nursing staff assigned to a unit shall participate in monitoring of the residents who are on visual checks. The nurse in charge will inform the nursing staff that a resident is to be observed and the frequency of the checks. Residents will be placed on visual checks as determined by the Interdisciplinary Care Plan Team or that are at risk for safety concerns as determined by the nurse in charge or supervisor. To monitor the residents in accordance with frequency schedule.A facility's policy and procedure titled Visual Checks dated 06/16/2020, documented room checks will be done on all shifts to help ensure that our residents' environment remains as free from accident hazards as possible and for each resident to receive adequate supervision and /or assistance. The Room Checks (also known as rounds) will establish the frequency of observing residents' activities and aim to prevent falls. During the designated time, Room Check or Rounds will be conducted on all residents in the unit. Hourly room checks will be done during the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shift. Half- hourly room checks are to be done during the 11:00 PM-7:00 AM shift. A facility's Policy and Procedure titled One-to-One Monitoring and Resident Supervision dated 03/18/2019, documented the facility does not provide one-to-one monitoring for fall prevention. Fall risk is managed through comprehensive assessment, individualized care planning, environment safety measures, staff supervision, and interdisciplinary interventions, rather than continuous individual observation. Resident #1 was admitted to the facility with diagnoses including malignant neoplasm of prostate, anemia, Non-Alzheimer's Dementia, and depression.The Minimum Data Set (an assessment tool) dated 11/03/2025, documented Resident #1 cognition was severely impaired. Resident #1 required supervision or touching assistance with transfer and ambulation from bed-to-chair- to-bed. A Fall Risk assessment dated [DATE] documented Resident #1 was identified as high risk for fall. A review of the instructions for Certified Nursing Assistant (Kardex) dated 07/28/2025, revealed providing supervision/oversight to the resident at least once every hour. Observations were performed at set intervals to address the resident's needs, ensure safety, prevent accidents, and report any concerns to the nurse.An Accident Report dated 11/21/2025 at approximately 8:15 PM, documented Registered Nurse #1 observed Resident #1 sitting on the floor on the right side of their wheelchair. Resident #1 was assessed by Registered Nurse Supervisor #1. There was no visible injury. Resident #1 verbally complained of back pain and the pain was 3/10 on the pain scale. The Medical Doctor #1 and the Emergency Contact #1 were notified. Pain medication was given with effect. A Lumbosacral Spine x-ray revealed a diagnosis of osteopenia (condition characterized by lower-than-normal bone mineral density, which can lead to an increased risk forf fracture), scoliosis (condition characterized by an abnormal side-to-side curvature of the spine), and spondylosis (degenerative changes in spine) noted with immediate degenerative disc disease. No fractures were identified. The facility's plan included to remind Resident #1 to ask for assistance, use call bell for assistance, keeping personal items and call bell within reach, and maintain half hour visual checks through purposeful room checks or rounding. The facility's investigation concluded that no abuse or neglect occurred, and the incident was unavoidable. An Accident Report dated 12/08/2025 at approximately 9:17 PM, documented Certified Nursing Assistant #1 observed Resident #1 lying on the floor, inside their room. Resident #1 was assessed by Registered nurse Supervisor #2. There was no visible injury. Resident #1 complained of lower back pain. The medical doctor and the emergency contact #1 were notified. Pain medication was given and was effective. Lumbosacral and bilateral hips were ordered. The x-ray result revealed mild degenerative changes in the left hip and degenerative changes in lumbosacral spine. There were no fractures. The facility's plan included to maintain bed in lowest position and to maintain half hour visual checks through purposeful rounding. The facility's investigation concluded that no abuse or neglect occurred, and the incident was unavoidable most likely due to behavioral habits of non-compliance and self-autonomous acts.An Accident Report dated 12/16/2025 at approximately 6:40 PM, documented while Registered Nurse Supervisor #3 was conducting rounds they observed Resident #1 lying on the floor, at the left side of the bed. There was no visible injury. Resident #1 reported pain in their left knee and elbow. A pain patch was applied to left knee and elbow. The pain medication was given and effective. Medical Doctor #1 and the Emergency Contact #1 were notified. An x-ray of the left knee and left elbow were ordered. The x-ray result showed the left knee was normal no fractures or dislocation. The left elbow showed normal alignment without fracture or dislocation. The facility's plan included to maintain bed in lowest position and maintain half hour visual checks through purposeful rounding. The facility's investigation concluded there was no abuse or neglect occurred.An Accident Report dated 12/29/2025 at approximately 11:07 AM, documented Resident #1 was taken to their room after their breakfast for incontinent brief change and refused to go back to dining room. Resident #1 was placed comfortably in bed and instructed to use call bell when needed assistance. At 11:07 AM, Housekeeping Aide #1 observed Resident #1 sitting on the floor in their room beside their bed and notified Registered Nurse #4. Resident #1 stated they tried to grab some food and lost their balance. Resident #1 was assessed by Registered Nurse #4. The Medical Doctor #1, and the emergency contact #1 were notified. Emergency Contact #1 requested hospital transfer for an evaluation. Resident #1 returned from emergency department visit with primary diagnoses of urinary tract infection and acute kidney injury. The facility's plan included to maintain bed in lowest position and maintain half hour visual checks through purposeful rounding. The facility's investigation concluded that no abuse or neglect occurred, and the incident was unavoidable most likely due to behavioral habits of non-compliance and self-autonomous acts.An Accident Report dated 01/05/2026 at approximately 1:50 AM, documented Certified Nursing Assistant #5 observed Resident #1 ambulating near their room door in the hallway while holding the handrails, Certified Nursing Assistant #5 ran but unable to reached Resident #1. Resident #1 lowered themselves on the floor in a sitting position. Resident #1 was assessed by Registered Nurse Supervisor #1. There was no visible injury. Resident #1 did not complain of pain. The emergency contact #1 and #2 were notified. The medical doctor #1 was notified and ordered stat (immediately) bilateral x-ray, bilateral hip, urine analysis and culture and sensitivity, complete blood count, complete metabolic panel, hemoglobin A1C, stat echocardiogram (ultrasound to create images of the heart), stat orthopedic appointment and to send Resident #1 to hospital for further evaluation. Emergency Contact #1 was notified and refused hospital transfer. An x-ray results of left knee showed no acute fractures, right knee showed mild osteopenia, lumbosacral spine showed no acute fracture and with degenerative changes and bilateral hips showed mild arthritic changes without obvious fracture. The facility's plan included to maintain bed in lowest position and maintain half hour visual checks through purposeful rounding. The facility's investigation concluded that no abuse or neglect occurred, and the incident was unavoidable most likely due to behavioral habits of non-compliance and self-autonomous acts.A review of the Accident Reports dated 11/21/2025 through 01/05/2026 the facility's plan to maintain half hour visual checks through purposeful rounding was not implemented in Resident #1's care plan.A review of fall care plan revealed there was no documented evidence of supervision reflected in Resident #1's care plan to implement adequate supervision until after the fall in 01/05/2026 at 1:50 AM.A review of Daily Resident Room Check (rounds) dated 11/21/2025, 12/08/2025, 12/16/2025, 12/29/2025 revealed Resident #1 was on hourly monitoring. An hourly monitoring (1 hour) was not reflected in the care plan.A review of Daily Resident Room Check (rounds) dated 01/05/2026 revealed Resident #1 was on half hour (30 minutes) monitoring. A half hour monitoring (1/2 hour) was not reflected in the care plan.During an interview on 01/06/2026 at 10:00 AM, the Emergency Contact #1 stated they made numerous complaints to the facility. Emergency Contact #1 stated Resident #1 had fall accidents on 11/25/2025, 12/08/2025, 12/16/2025, 12/29/2025 and 01/05/2026. Emergency Contact #1 stated despite their questions to Medical Doctor #1 and Director of Nursing there was no explanation for the fall incidents. Emergency Contact #1 stated they always tell them that they found Resident #1 on the floor. Emergency Contact #1 stated they asked the facility to implement fall prevention tactics and maybe Resident #1's dementia was worsening. Emergency Contact #1 stated they can conclude that facility was unable to provide supervision for Resident #1. Emergency Contact #1 stated there were no updated instructions in Resident #1's care plan.During an interview on 01/12/2026 at 3:39 PM, Certified Nursing Assistant #1 stated they were the regular assigned staff when Resident #1 had fall incidents during the evening shift (3:00 PM-11:00 PM). Certified Nursing Assistant #1 stated they monitor Resident #1 every hour along with all other residents on the unit during their shift . Resident #1 had more frequent visual checks because Resident #1 was a high risk for fall. Certified Nursing Assistant #1 stated they could not describe what more frequently meant but could be every 30 minutes. Certified Nursing Assistant #1 stated they do not document when Resident #1 was monitored more frequently. Certified Nursing Assistant #1 stated there were no specific orders or instructions for more than hourly rounds. Certified Nursing Assistant #1 stated Resident #1 had aggressive behavior and combative behavior of pushing and hitting them and Resident #1 tells them to leave them alone. Certified Nursing Assistant #1 stated there were no more activities going on after dinner in the day room During an interview on 01/14/2026 at 7:59 AM, Certified Nursing Assistant #6 stated they worked the night shift (11:00 PM-7:00 AM) on 01/05/2026. Certified Nursing Assistant #6 stated during their shift Resident #1 was monitored every 30 minutes as with the other residents. Certified Nursing Assistant #6 stated when they arrived on the unit, they saw Resident #1 pacing back and forth in the hallway. Certified Nursing Assistant #6 stated when Resident #1 was sleepy in their wheelchair, they put them to bed and later, they observed Resident #1 trying to get up unassisted. Certified Nursing Assistant #6 stated when Resident #1 was restless they watched them in the nursing station and offered them snacks. Certified Nursing Assistant #6 stated Resident #1 was now monitered every 15 minutes to prevent from fall.During an interview on 01/12/2026 at 11:19 AM, Registered Nurse Supervisor #3 stated they were doing their rounds on the unit on 12/16/2025 at 6:40 PM when they saw Resident #1 lying on the floor on the left side of their bed. Registered Nurse Supervisor #3 stated they assessed Resident #1 and there was no visible injury. Registered Nurse Supervisor #3 stated prior to the incident Resident #1 was observed by staff wheeling themself to their room and wanted to stay in room and go to bed. Registered Nurse Supervisor #3 stated they updated the care plan. Registered Nurse Supervisor #3 stated although Resident #1 was on hourly monitoring during the day shift and evening shift, staff were encouraged to check Resident #1 more frequently. Registered Nurse Supervisor #3 stated when they say more frequently, they do not have specific time, but they visually check Resident #1 more often but not documented. Registered Nurse Supervisor #3 stated they noticed the hourly monitoring for day shift and evening shift and half hour monitoring for night shift was not documented in Resident #1's care plan. Registered Nurse Supervisor #3 stated they do not know why there were no documentations.During an interview on 01/14/2026 at 8:32 AM, Registered Nurse Supervisor #2 stated they were notified on 12/08/2025 at 9:17 PM by Registered Nurse #2. Registered Nurse Supervisor #2 stated Resident #1 was assessed and there was no visible injury. Registered Nurse Supervisor #2 stated they have lists of residents that are at a high risk for fall in each unit and staff were aware. Registered Nurse Supervisor #2 stated they update and reflected the incident in the care plan and check interventions. If needed new intervention are included. Registered Nurse Supervisor #2 stated their Risk Management #1 (Assistant Director of Nursing #1) in the morning received and reviewed incident reports and reviewed the care plan interventions. Registered Nurse Supervisor #2 stated, them and the unit nurses were responsible for ensuring staff implementing the care plan interventions.During an interview on 01/14/2026 at 8:57 AM, Registered Nurse Supervisor #4 stated they were notified of the incident on 12/29/2025 at 11:07 AM. Registered Nurse Supervisor #4 stated they assessed Resident #1 and there were no visible injury. Registered Nurse Supervisor #4 stated they provide adequate supervision to Resident #1 by keeping them in the day room, frequent visual checks hourly during the day and evening and half an hour in the night shift. Registered Nurse Supervisor #4 stated they believed Resident #1 had adequate supervision by keeping them in the day room with a certified nursing assistant assigned.During an interview on 02/02/2026 at 11:01 AM, Registered Nurse Supervisor #1 stated they worked on 11/21/2025 and 01/05/2026 during the incidents. Registered Nurse Supervisor #1 stated they assessed Resident #1 and there were no visible injuries. Registered Nurse Supervisor #1 stated they had monitoring log for each shift. Registered Nurse Supervisor #1 stated incidents are documented in the care plan with interventions. Registered Nurse Supervisor #1 stated the Risk Manager (Assistant Director of Nursing #1) will review incidents and the care plan interventions. Registered Nurse Supervisor #1 stated Resident #1 was closely supervised by staff by checking them more frequently like every 5 minutes because Resident #1 had history of multiple falls. Registered Nurse Supervisor #1 stated on 01/05/2026, Resident #1 has a restlessness behavior prior to the fall, and they realized Resident #1 required increased supervision and they implemented in care plan to visual check Resident #1 every 15 minutes to prevent further occurrence of fall because when Resident #1 was placed in bed and tried to get up unassisted.During an interview on 01/12/206 at 1:20 PM, Director of Nursing stated all the fall incidents were investigated. Director of Nursing stated Resident #1 was closely supervised by keeping them in the day room during meals, toileted every 2 hours and as needed, kept engaged with activities and staff continued to monitor Resident #1. Director of Nursing stated they have interventions in place to prevent fall, and it was just that their monitoring was not implemented in their care plan until on 01/05/2026 when the staff implemented fifteen (15) minute monitoring to further monitor Resident #1. The Director of Nursing stated if Resident #1 requires one-to-one supervision they will send them to hospital. Director of Nursing stated other interventions such as bed alarm and chair alarm were implemented. The Director of Nursing stated that the falls were unavoidable because Resident #1 was non-compliant with safety measures.During an interview on 02/02/2026 at 10:50 AM, the Administrator stated they do not provide service of one-to-one supervision in their facility regarding fall prevention. The Administrator stated Resident #1's care plan had adequate supervisions interventions in place such as the 15-minute monitoring placed on 01/05/2026, bed alarm, chair alarm, day room monitoring that were successful.10NYCRR415.12(h)(2)

Based on observation, interview, and record review conducted during the Abbreviated Survey (NY00337289), the facility failed to ensure residents had the right to obtain a written decision regarding their grievance. This was evident for one (1) of three (3) residents sampled (Resident #1). Specifically, on 11/24/2024, 01/24/2025, 01/28/2025, and 02/27/2025, Resident #1's Health Care Proxy requested written results for the filed grievances. The request was sent on an e-mail to the Administrator. The written results were not provided to Resident #1's Health Care Proxy. The findings are: The facility policy titled, Grievance/Complaint Policy, dated 11/17/2017, documented the facility shall establish written policies and procedures to process all complaints and recommendations initiated by individual patients/residents, their Designated Representatives or family members, as well as by the Resident Council in the general forum. The facility will notify the resident individually or through posting in prominent locations throughout the facility of the right to obtain a written decision regarding his or her grievance. Resident #1 was admitted to the facility with diagnoses including Dementia, Altered Mental Status, and Toxic-metabolic encephalopathy. The Minimum Data Set (an assessment tool) dated 03/18/2024 identified Resident #1's cognition as severely impaired. An Email dated 11/24/2024 was sent to the Facility Administrator documented Resident #1's Health Care Proxy requested written confirmation of the steps being taken regarding their parent being found on multiple occasions wet and soiled. A review of the Grievance /Complaint Form dated 01/12/2025, sent via email to the Facility's Administrator documented Resident #1 Health Care Proxy filed a grievance about their parent being found with wet, incontinent brief and pants. A review of the Grievance/Complaint Form dated 01/24/2025, was sent via email to the Facility's Administrator documented Resident #1's Health Care Proxy requested written confirmation detailing how an Unlicensed Social Worker diagnosed medical conditions, will be addressed. A review of the Grievance/Complaint Form dated 01/28/2025, sent via email to the Facility's Administrator documented Resident #1's Health Care Proxy requested a written response on their grievance regarding Specialist Care, Resident #1's treatment, and how inaccurate comments made by the Administrator during the 01/23/2025 care plan meeting. A review of the email dated 02/18/2025 sent to the Facility's Administrator documented that Resident #1's Health Care Proxy submitted an inquiry of the Grievance Procedure. A Grievance/Complaint Form dated 02/18/2025, documented the Interdisciplinary team attempted to contact Resident #1's Health Care Proxy with the outcome of the investigation of Resident #1 that was found wet on 02/12/2025, but they were unavailable. A voice message was left. A review of the Grievance/Incident Form dated 02/22/2025, sent via email to the Facility's Administrator documented Resident #1's Health Care Proxy requested a written response on the incident dated 02/12/2025 when Resident #1 was left unchanged and all prior incidents. A review of the Amended Grievance/Incident Form dated 02/22/2025, sent via email to the Administrator documented Resident #1's Health Care Proxy requested a written response on their grievance dated 02/21/2025. A review of the email dated 02/27/2025, sent to the Facility's Administrator documented Resident #1's Health Care Proxy requested the facility's grievance and incident procedures in writing. Resident #1's Health Care Proxy also requested copies of all grievance incidents decisions from 03/11/2024 to present to be sent via regular mail, ensuring the correct address is used. There was no documented evidence that Resident #1's Health Care Proxy requested to review Grievances results prior to mailing. During a telephone interview on 02/20/2025 at 12:52 PM, the Director of Social Service was the grievance officer and responsible for investigating grievances. The Director of Social Service stated they have five business days to investigate the grievance, and they will then notify the complainant verbally over the phone or in person. The Director of Social Service stated they provided verbal outcome of the grievance and did not provide the written results. During a telephone interview on 03/10/2025 at 12:50 PM, Resident #1's Health Care Proxy stated they requested verbal and written response to filed grievances but did not receive any written response to their grievances. During a telephone interview on 03/21/2025 at 1:45 PM, the Facility's Administrator stated the Director of Social Service is responsible for the Grievance process in the facility. The Facility 's Administrator stated the Social Service and Interdisciplinary Team was responsible for providing the results and / or resolution of the grievances to residents or their representatives. The Facility's Administrator further stated residents, or their representatives are entitled to receive a copy of the Grievance intake and a summary of the investigation. The Facility's Administrator stated they received a request from Resident #1's Health Care Proxy for a copy of the grievances and to review them in person. The Facility Administrator stated they set up meetings on 03/12/2025, but Resident #1's healthcare Proxy did not show up despite confirmation of attendance. The Facility's Administrator stated another meeting was set up on 03/18/2025 at 11:00 AM, but Resident #1's Health Care Proxy came later at 11:45 AM and asked if they could review the Grievance copies on another meeting, but no date or time was provided. The Facility's Administrator stated that copies of the grievances were not mailed to Resident #1's Health Care Proxy because they requested that they are reviewed in person. 10 NYCRR 415.3(d)(1)(ii)

Based on observation, record review, and interviews conducted during an Abbreviated Survey (NY00358641), the facility did not ensure the residents' right to be free from physical abuse by nursing home staff. This was evidence for 1 out of 10 residents reviewed (Resident #1). Specifically, on 10/25/2024 at 2:52 PM, in the nursing station as Resident #1 approached Admission Clerk #1 with the arms raised to Admission Clerk #1's neck area. Admission Clerk #1 pushed Resident #1 with both hands and Resident #1 fell backward on the floor and hit their head on the desk behind them. Resident #1 was transferred to the hospital for evaluation and returned to the facility with no new orders. The findings are: The facility's Policy and Procedure Reporting and Investigation of Resident Abuse, Neglect, Misappropriation/ Exploitation and Mistreatment, effective date 10/2022, documented the purpose of the policy to ensure that every resident have the right to be free from abuse, neglect, mistreatment, misappropriation of resident property and exploitation. To provide a safe environment and protect residents from abuse. Resident #1 was admitted to the facility on [DATE], with diagnoses that include Vascular Dementia, Psychotic Disorder with Delusions, and Major Depressive Disorder. The Minimum Data Set (a resident assessment tool) dated 08/23/2024, documented Resident #1 had severe cognitive impairment. A Facility's Incident Investigation Report dated 10/25/2024, documented that at approximately 3:00 PM, code Doctor Strong was called, and Resident #1 was observed on the floor behind the nursing station. The video surveillance was reviewed, and it was observed that prior to the incident, Resident #1 was sitting in the front of the nursing station. When Admission Clerk #1 entered the nursing station, Resident #1 followed Admission Clerk #1. Admission Clerk #1 turned around as Resident #1 walked toward Admission Clerk #1. Resident #1 raised their arms as they walked toward Admission Clerk #1, and Admission Clerk #1 pushed Resident #1 away. As a result, Resident #1 fell backward onto their bottom and hit the cabinet behind them. The New York City Police was called, but no arrest was made. The facility determined that the occurrence was unsubstantiated for physical abuse. Admission Clerk #1 acted out of fright and reacted to Resident #1's behavior. A Care Plan for Resident at risk for being a victim of abuse, neglect, and/or mistreatment due to congregate living initiated on 11/17/2020, target date 02/25/2025, documented interventions to advise resident to seek out staff assistance if having difficulty with others. A Care Plan Note dated 10/25/2024 at 5:57 PM, written by the former Director of Nursing documented they arrived at the Doctor Strong code (Doctor Strong code means the resident is agitated). Resident #1 fell and hit their head. Resident #1 alleged that a staff member hit them. Resident #1 noted with redness to the back of their head and ice was applied. Resident #1 denied pain. A full body assessment was done, and no other new bumps, bruising, redness, irritation, or swelling were noted. Resident #1's range of motion was intact. The primary medical doctor was made aware, and Resident #1 was transferred to the Hospital emergency department. A Physician Progress Note dated 10/25/2024 at 04:19 PM, documented Resident #1 noted to have violent behavior towards staff. During their behavior, Resident #1 fell and hit their head. No Loss of Conscious and was sent to Emergency Department. A Physician Order dated 10/25/2024, documented transfer Resident #1 to the hospital for evaluation. A Hospital After Visit Summary dated 10/25/2024, documented Resident #1 was evaluated for hitting their head; computerized Tomography was done and there were no injuries. A video surveillance record dated 10/25/2024 at 2:52 PM, showed Admission Clerk #1 was standing by the desk in the nursing station. Certified Nurse Assistant #1 was sitting at the desk with their back turned to Admission Clerk #1. Licensed Practical Nurse #1 was standing at the medication cart. Resident #1 walked into the nursing station, passed Licensed Practical Nurse #1, approached the Admission Clerk #1 with raised their hand, and attempted to reach the Admission Clerk's neck area. The Admission Clerk #1 pushed Resident #1 with both hands, and they fell backward on the floor. During an interview on 12/05/2024 at 11:20 AM, Admission Clerk #1 stated they do not want to answer any questions. During an interview on 12/05/2024 at 12:48 PM, Certified Nursing Assistant #1 stated Resident #1 was known for aggressive behavior in the past. Certified Nursing Assistant #1 stated around 3:00 PM while sitting in the nursing station at the computer saw Resident #1 walk into the nursing station and walk toward the Admission Clerk #1. Resident #1 raise their hands toward the Admission Clerk #1. Certified Nursing Assistant #1 further stated they saw Resident #1 fall backward but did not see what caused them to fall. Certified Nursing Assistant #1 stated there was no time to intervene because it happened very fast. Certified Nursing Assistant #1 stated Licensed Practical Nurse #1 called Doctor Strong, (when the resident agitated), and the Nursing Supervisor came and took over. During an interview on 12/6/2024 at 2:03 PM, Certified Nursing Assistant #2 stated on 10/25/2024, after 2:00 PM, they were sitting in the nursing station. Certified Nursing Assistant #2 stated they observed Resident #1 enter the nursing station, pass them, and was talking. Certified Nursing Assistant #2 stated they thought Resident #1 was talking to the nurse who was behind them. Certified Nursing Assistant #2 stated that they were sitting with their back to Resident #1 and heard Resident #1 say, You called me N but they did not know who Resident #1 was referring to. Certified Nursing Assistant #2 stated they turned around because they heard a noise like a wrestle and dump. Certified Nursing Assistant #2 stated they observed Resident #1 was on the floor and holding the back of their head. Certified Nursing Assistant #2 stated Resident #1 had a lump on the back of their head but did not complain of pain. Certified Nursing Assistant #2 stated Resident #1 said the Admission Clerk #1 hit them. Certified Nursing Assistant #2 stated they asked the Admission Clerk #1 what happened, and they said that Resident #1 tried to attack them, and they defended themselves. Certified Nursing Assistant #2 stated they were showed the video, and saw Admission Clerk #1 hit or push Resident #1, causing Resident #1 to fall on the floor. Certified Nursing Assistant #2 stated they are not supposed to touch the resident. Certified Nursing Assistant #2 stated in a situation when residents become aggressive, staff should back away or remove themselves from the situation and call for help. Certified Nursing Assistant #2 stated if there is no way to escape, the staff is supposed to raise their hands to block the hit, but they cannot push or hit the resident. During a telephone interview on 12/05/2024 at 1:20 PM, Licensed Practical Nurse #1 stated Resident #1 came to the nursing station on 10/25/24 after lunch (could remember the exact time) and was approaching Admission Clerk #1 aggressively. Licensed Practical Nurse #1 stated Resident #1 passed them, and they did not feel they could have the opportunity to intervene and stop Resident #1. Licensed Practical Nurse #1 stated they saw Resident #1 raise their arms toward the Admission Clerk #1 but did not see if the Admission Clerk #1 pushed Resident #1. Licensed Practical Nurse #1 stated they turned to the left to grab the walkie-talkie that was on the desk and called the Doctor Strong code. Licensed Practical Nurse #1 stated at the time they turned around; Resident #1 was already on the floor. Licensed Practical Nurse #1 stated that the Registered Nurse Supervisor assessed Resident #1. Licensed Practical Nurse #1 stated Resident #1 had a bump on the back of the head and did not complain of pain. Licensed Practical Nurse #1 stated the Medical Doctor was called and ordered to send Resident #1 to the hospital. Licensed Practical Nurse #1 stated the Administrator showed them the video, and they saw Admission Clerk #1 push Resident #1 who fell on the floor. During an interview on 12/06/2024 at 2:33 PM, Registered Nurse Supervisor #1 stated they did not have full details of what happened until a review of the video showed that the Admission Clerk #1 pushed Resident #1 and caused them to fall. Registered Nurse Supervisor #1 stated it was not acceptable to push Resident #1 in response to aggressive behavior. Registered Nurse Supervisor #1 stated proper protocol was if there was no way to escape, do not respond, do not react, shield from the aggressor, and call for help. Registered Nurse Supervisor #1 stated the supervisor and facilitys educator are responsible for monitoring staff and how they responded to aggressive behaviors and not to abuse residents. During an interview on 12/06/2024 at 4:20 PM, the Director of Nursing stated they recently started in the facility and the incident was investigated by the former Director of Nursing. The Director of Nursing stated when the resident is aggressive to the staff, the staff should walk away and call for help and not retaliate. During an interview on 12/06/2024 at 4:36 PM, the Administrator stated the former Director of Nursing informed them about the incident and they reviewed the video with the former Director of Nursing. They observed the interaction between Admission Clerk #1 and Resident #1 and initiated the investigation. The Administrator stated the Admission Clerk #1 was suspended during the investigation. The Administrator stated the police were called, but no arrest was made. The Administrator stated the police said it was self-defense and Resident #1 could not file a report because they were the aggressor. The Administrator stated the Admission Clerk #1 was terminated because they violated facility's policy and procedure. The Administrator stated Admission Clerk #1 should have initiated a Doctor Strong code (call for help). The Administrator stated the charge nurses, supervisors, and Director of Nursing are responsible for monitoring residents to ensure that the residents are free from abuse and received proper care. 10 NYCHRR 415. 4(b)(1)(ii)

Based on observation, record review, and interviews conducted during the Recertification survey from 4/7/24 to 4/12/24, the facility did not ensure that food was prepared, distributed, and served food in accordance with professional standards for food service safety. This was evident during observations during the Kitchen facility task. Specifically, 1) the dish washing machine did not maintain appropriate temperatures for washing and rinsing dishes, 2) hair was not covering appropriately by dietary staff preparing and serving meals, 3) the temperatures of food on the steam table was not checked or recorded prior to meals being served and, 4) food in unit pantry was not labeled and dated appropriately. The findings are: 1. The facility policy and procedure titled Dish Machine Procedure with an effective date of May 2022 documented dish washer/dietary aide will report the machine for immediate repair if temperatures are not adequate. The policy also documented that the rinse temperature is 150 min, wash temp 160 min and final rinse 180 min and did not document the temperatures as Centigrade or Fahrenheit. The policy further documented that the Manager/Supervisor will monitor wash and rinse temperatures periodically through shift to ensure proper temperature. On 04/09/24 at 10:27 AM, an observation was conducted of the dish machine which registered temperatures as follows: wash 142 degrees F, rinse 142 degrees F, and final rinse 188 degrees F. The Director of Dietary Department was interviewed immediately and stated that they were not aware that the wash and rinse temperatures were not being reached on the dish machine, and they would contact maintenance. On 04/10/24 at 12:59 PM, a follow-up observation was conducted of the dish machine. Temperature were wash-141 degrees F, rinse-141 degrees F, and final rinse 193 degrees F. The Dishwasher Temperature Log for April 2024 Day 1 to Day 9 documented wash temperatures were between 154-165 degrees F at Breakfast, 160-165 degrees F at Lunch, and 160-170 degrees F at Dinner. Rinse temperatures were between 159-175 degrees F at Breakfast, 168-179 at Lunch, and 175-186 at Dinner. Final Rinse temperatures were within the 175-180 range at Breakfast, 175-179 range at Lunch, and 180-190 range at Dinner. On 04/10/24 at 01:24 PM, an interview was conducted with the Director of Dietary Department who stated that the dish machine was not meeting wash and rinse temperatures and they contacted the vendor on 4/9/24 who stated that they would order a part for the machine which would be sent to the facility overnight. The Director of Dietary Department also stated that the part would not arrive now until 4/11/24. The Director of Dietary Department further stated that they contacted corporate and were told they could continue using the dish machine even though the wash and rinse temperatures were not high enough as long as the final rinse temperature was high 180 degrees F or higher. 2. On 04/10/24 at 12:01 PM, the Dietary Supervisor was observed on unit B5 dressed in street clothes behind the steam table, removing the coverings from the food items. The Dietary Supervisor had upper part of hair uncovered and hair net was observed loosely covering the ends of braids in their mid-back area. On 04/10/24 at 01:44 PM, the Dietary Supervisor was interviewed and stated that at the beginning of each shift they observe dietary staff to ensure that they have put on hair nets, have washed their hands, and are dressed in uniform scrubs or burgundy shirts and scrub pants. The Dietary Supervisor also stated that all hair has to be up in hair net, and if needed facial hair beard guard is worn. The Dietary Supervisor further stated that their hair is heavy so they have to wear two hair nets and they were not aware that their hair was not covered. The Dietary Supervisor stated that their clothing should have been covered with a lab coat or apron and they usually wear their lab coat on the unit but was rushing so left the lab coat behind in the kitchen. 3. The facility policy and procedure titled Warming Unit Table Service with an effective date of February 2017 documented that the Dietary Aide will bring ice water in cup and calibrate thermometer, will take temperature of food, one pan at a time, wiping probe after each use to ensure that food is at a proper serving temperature and have designee record on log. The policy also documented that food will immediately be served after confirmation of proper food temperature. On 04/09/24 at 11:50 AM, Dietary Aide #1 arrived on unit B2, sanitized hands with alcohol based hand rub and put on a pair of gloves. Dietary Aide #1 was observed to have hair partially covered with pony tail at base of neck not covered by the hair net. In addition, Dietary Aide #1 was observed to be wearing a mask that did not cover their nose. Dietary Aide #1 uncovered all food items, sanitized hands with alcohol based hand rub, then placed utensils into each food item. On 04/09/24 at 12:07 PM, Dietary Aide #1 was observed taking the temperature of chicken parmesan only and placed the thermometer in the ice bath without first cleaning the probe. Dietary Aide #1 then served chicken parmesan, pasta, vegetables, and mechanical chicken, pasta without checking the temperature of all food items. Dietary Aide #1 then checked the temperature of the pasta at 12:10 PM, the vegetables at 12:12 PM, and the baked chicken at 12:15 PM. Dietary Aide #1 did not wipe the probe between checking food items. On 04/09/24 at 12:17 PM , Dietary Aide #1 checked the temperature of the stuffed cabbage, served mashed potato at 04/09/24 at 12:21 PM without checking the temperature, and checked the temperature of the mechanical chicken at 12:22 PM. On 04/09/24 at 12:26 PM, pureed chicken and vegetables were served without the temperature being checked. On 04/09/24 at 12:29 PM, the temperature of the pureed chicken was checked. On 04/09/24 at 12:32 PM, Dietary Aide #1 changed gloves, did not perform hand hygiene, and checked the temperature of the mashed potatoes. Temperatures for the pureed vegetables, mechanical vegetables, and hamburger were not checked before the foods were served. Food temperatures were not recorded and the thermometer was not cleaned between each food item. On 04/09/24 at 12:39 PM, Dietary Aide #1 removed their gloves, unplugged steam table, removed utensils, and did not perform hand hygiene. On 04/10/24 at 01:05 PM, Dietary Aide #1 was interviewed and stated that they are supposed to check food temperatures before food is served to ensure it is at the right temperature but did not do this on 4/9/24 because they came to the unit late so checked the temperatures of the food one by one. Dietary Aide #1 stated that the thermometer is supposed to be cleaned after checking each food item, but they forgot to bring alcohol wipes with them. Dietary Aide #1 also stated that temperature of food is supposed to be documented in the log book on the truck inside the fridge and that sometimes they log the temperatures of food after meal service Dietary Aide #1 further stated that they are supposed to have hair fully covered and are taught to wash hands and sanitize. Masks are supposed to cover the nose, but sometimes it is a little hard to keep it in place. Dietary Aide #1 stated they do receive in-service in these things and last inservice was about 2 weeks ago. On 04/10/24 at 01:24 PM, the Director of Dietary Department was interviewed and stated that dietary staff are supposed to take the temperatures of food at start of service and are supposed to record the temperatures right then and there in the log book. Supervisors are supposed to make sure that staff are taking the temperatures each meal service. The Director of Dietary Department also stated that staff wash their hands in the kitchen downstairs, then they sanitize their hands when they get to the unit before they put on their gloves. Masks are supposed to be worn covering their nose and mouth in resident care areas and all hair is supposed to be covered. The Director of Dietary Department further stated that the supervisor is supposed to monitor the dietary staff and it is supposed to be a team effort. 48876 4. The facility policy titled Food Storage and Pantry Refrigerator Temperature effective date 2/2024 documented food stored in the pantry refrigerator, will be labeled with name, room number and the date the food was stored to ensure it is discarded after 48 hours. Commercially packed items will be discarded based on the manufacturer's expiration date. The nursing staff will remove and discard all unlabeled food each morning. The Director of Nursing and Director of Maintenance shall ensure compliance with this policy. On 4/9/2024 at 3:43 PM, the Director of Housekeeping was present during observation of the 3rd Floor pantry refrigerator. The refrigerator was observed to contain one unlabeled and undated ham sandwich, and 2 plastic containers of water which held numerous individual packets of coffee creamers and vegetable spreads that did not have expiration dates. On 4/9/2024 at 3:44 PM, Registered Nurse #5 was interviewed and stated that resident food in the pantry refrigerator should be labeled with preparation date, and name of the resident and that all foods and liquids should be discarded 48 hours after the preparation date. On 4/9/2024 at 3:45 PM, the Director of Nursing arrived on the 3rd Floor and observed the contents of the pantry refrigerator and stated all food in the pantry refrigerator from the facility kitchen should be dated and discarded after 48 hours. 10NYCRR 415.14

Based on observations and interviews conducted during the Recertification survey from 4/7/24 to 4/12/24, the facility did not ensure that garbage and refuse were disposed of properly. Specifically, the garbage was not properly contained outside of the facility and various types of garbage were observed overflowing from the top of the dumpster. The finding is: The facility policy and procedure titled Proper Disposal of Garbage and Refuse effective date 11/2016 documented that the Food Service Director/Manager will monitor the garbage containers to ensure they are in good condition (no leaks) and with lids and evaluate loading docks, hallways, elevators that are used for both garbage and food transport are kept clean and free of foul odors. On 4/9/24 at 10:37 AM, an observation was made of the garbage disposal area. A large dumpster was observed containing cardboard, plastics, a white metal frame, papers, wood, and trash bags were observed hanging over edge of the dumpster. There was no covering over the dumpster. Dietary Aide #2 was observed throwing two bags of garbage into the open dumpster and placing cardboard into the compactor. Dietary Aide #2 was interviewed immediately and stated that the regular dumpster had been picked up and they were using this replacement dumpster which did not have a cover. Dietary Aide #2 also stated that the dumpster that was there had a door that closed, but this dumpster was temporary and did not have a cover. On 04/09/24 at 10:49 AM, Housekeeper #2 was observed approaching the garbage disposal area accompanied by the Director of Housekeeping. Housekeeper #2 placed four additional large garbage bags on top of the overflowing dumpster. The Director of Housekeeping was interviewed immediately and stated that the facility dumpster was leaking so was picked up on 4/7/24 by the vendor to be repaired. The Director of Housekeeping also stated that the vendor did not provide a cover for the dumpster, and they only expected the repair of the compactor to take one day. The Director of Housekeeping further stated that the dumpster should have been covered and they would try to cover it now. On 04/10/24 at 01:24 PM, the Director of Dietary Department was interviewed and stated that they were not aware of when the compactor had been changed to a dumpster as the facility usually uses a compactor. The Director of Dietary Department also stated that they do not usually go out to the garbage disposal area, but they ensure that any garbage leaving the kitchen is in covered bins. On 04/10/24 04:42 PM, an interview was conducted with the Administrator who stated garbage should be in covered receptacles. The Administrator also stated that when the vendor leaves an open dumpster they do not provide a covering, but will cover it when they remove the dumpster. The Administrator further stated that the vendor told them that when garbage bags are closed, no covering is needed. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews conducted during the Recertification survey from 04/07/2024 to 04/12/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically. 1) Enhanced Barrier Precautions were not maintained during wound care, and 2) the Registered Nurse failed to sanitize the blood pressure cuff between Resident #27 and #163 during Medication Administration. The findings are but not limited to: 1. The Centers for Medicare and Medicaid Services (CMS) memo titled Center for Clinical Standards and Quality/Quality, Safety & Oversight Group. Ref: QSO-24-08-NH dated 03/20/2024 documented Enhanced Barrier Precautions recommendation now includes using enhanced barrier precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status-effective 04/01/2024. The facility policy and procedure titled Enhanced Barrier Precaution, last revised 04/01/2024, documented that all personnel, including visitors, who have direct contact with a resident with infection or colonization with a multidrug-resistant organism or with wounds and indwelling medical devices, even if the resident is not known to be infected or colonized with a multidrug will be observed enhanced barrier precautions. Enhanced barrier precautions involved gown and glove use during high-contact resident care activities, which provides opportunities to transfer multidrug-resistant organisms to staff hands and clothing. On 04/11/2024 at 11:32 AM, Registered Nurse #6 was obtained wound care treatment supplies and entered Resident #122's room. Registered Nurse #6 completed the dressing change appropriately and discarded soiled material in the soiled utility room. Registered Nurse #6 was not observed wearing a gown during the wound care treatment. There was no signage at the resident's room that Enhanced Barrier Precautions were in place or that personal protective equipment was required. On 4/11/2024 at 11:32 AM, Registered Nurse #6 was interviewed and stated that during a pressure ulcer dressing change, the nurse usually wears gloves and mask for infection control but no gown is needed. On 4/12/2024 at 9:45 AM, Registered Nurse #7 was interviewed and stated that staff need to have gloves, gown, and mask for the pressure ulcer dressing change. Registered Nurse #7 also stated that if the resident is on contact precautions, they will put the contact precautions signage at the entrance of the resident's room. Registered Nurse #7 further stated that if the resident has a wound and is not on contact precautions, staff go to the storage room where the personal protective equipment is kept, to get a gown, mask, and gloves for the dressing change. 39136 The facility records titled Residents on Enhanced Barrier Precautions last revised on 04/11/2024 documented the following: 9 residents with the multidrug-resistant organism 9 residents with Foley catheter 5 residents with Gastrostomy tube 18 residents with Permacath (CVP) for Dialysis 32 residents with wounds On 04/12/2024 at 8:46 AM, the Infection Preventionist was interviewed and stated that Enhanced Barrier Precautions are used for residents with Foley catheters, gastrostomy tubes, and Perma Cath. The staff is required to wear gloves and gowns during care, such as showering, changing their bedding, and performing catheter and wound care. Residents with multidrug-resistant organisms and indwelling medical devices, such as gastrostomy tubes, Foley catheters, Perma Cath, and PICC lines, are all supposed to be placed on enhanced barrier precautions. The Infection Preventionist also stated that they have residents whor receive dialysis with Permacaths, residents with gastrostomy tube, foley catheter, and chronic wounds, but these residents are not on Enhanced Barrier Precautions, because they just started to in-service their staff. The Infection Preventionist further stated they did not know that the Enhanced Barrier Precautions were supposed to be implemented already and that they planned to begin implementation on 4/15/2024. The Infection Preventionist stated that they are trying to educate all of the staff before implementing the Enhanced Barrier Precautions. On 04/12/2024 at 10:08 AM, the Director of Nursing was interviewed and stated that residents with indwelling medical devices and wounds are at risk of getting multidrug resistant organism. As of 04/01/2024, those residents should be placed on Enhanced Barrier Precautions. The Director of Nursing also stated that they have identified residents with indwelling medical devices and wounds who need to be placed on the Enhanced Barrier Precautions. They started in-service on the Enhanced Barrier Precautions and plan to implement it after they finished in-servicing the staff. The Director of Nursing further stated that they received the memo the last week of March and were supposed to implement the precautions effective 04/01/2024. On 04/12/2024 at 2:23 PM, the Administrator was interviewed and stated they did not receive the memo. They were notified by their Corporate office and initiated the policy on 04/01/2024. The Administrator stated that they cannot implement the Enhanced Barrier Precautions until all the staff are educated, and inservice of staff has started. 44864 2. The facility's policy titled Protocol for Disinfection of Residents Rooms and Equipment with effective date of 12/2023, documented that commonly used items such as the blood pressure machine, thermometer, blood pressure cuff, etc., should be disinfected in between use if contact with the equipment occurs. On 04/12/24 at 08:54 AM, during Medication Administration, Registered Nurse #2 was observed entering Resident's #163 room with the blood pressure machine. Registered Nurse #2 was not observed cleaning the blood pressure cuff prior to use. The blood pressure cuff was applied to Resident's #163 arm and blood pressure taken. Registered Nurse #2 then removed the blood pressure cuff and returned it to the machine, administered medication, and left the resident's room. Registered Nurse #2 then entered Resident's #27 room with the same blood pressure machine. Registered Nurse #2 placed the blood pressure cuff on Resident's #27 arm and obtained their blood pressure reading. Registered Nurse #2 did not sanitize the BP cuff in between use with Resident #163 and Resident #27. On 04/12/24 at 09:15 AM, Registered Nurse #2 was immediately interviewed and stated that they were supposed to clean the cuff with the germicidal wipes, and that they forgot to clean it. Registered Nurse #2 said that they were taught to clean it after every use. On 04/12/24 at 09:30 AM, Registered Nurse #1 was interviewed and stated that as the Supervisor on the unit, they are responsible to monitor the nurses as they administer the medications on the unit. The nurses were in-service and taught that they are supposed to clean the blood pressure cuff with the sanitizer, Clorox wipes, between resident's use. Registered Nurse #1 also stated that the nurses are initially in-serviced, and competencies are done by the educator, but the nurses are monitored periodically to ensure that they are doing the correct procedures. On 04/12/24 at 12:31 AM, the Registered Nurse Educator was interviewed and stated that they are responsible for educating the nurses on the mandatory tasks and policies. The nurses specifically are shown the tasks and then they do return demonstration. The Registered Nurse Educator also stated that the nurses must be able to sanitize the blood pressure cuff before and after use with each resident. The nurses are monitored through their competencies and then they would perform the task to ensure that they are doing it correctly. They are checked periodically to ensure that they are performing the skills correctly, and if any concerns are observed, a competency will be done to ensure accuracy. 10 NYCRR 415.19(b)(4)

Based on observations, record review, and interviews conducted during the Recertification Survey from 04/07/2024 to 04/12/2024, the facility did not ensure that the residents were treated with respect and dignity and cared for in a manner and environment that promotes enhancement of their quality of life. This was evident for one (Resident #158) of five residents reviewed for Dignity out of a sample of 38 residents. Specifically, Resident #158 was observed multiple times in their room with a strong urine odor. The findings are: The facility policy and procedure titled Dignity, last revised in November 2016, documented that the facility's policy is to ensure services are provided in a manner that enhances/maintains a dignified existence. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #158's cognition as moderately impaired with a Brief Interview for Mental Status score of 8, required supervision for toileting and hygiene, set-up only for personal hygiene, and was continent of urine and bowel. The Comprehensive Care Plan initiated on 06/19/2018 revised 2/9/24 documented that Resident #158 is continent of the bladder, at risk for bladder incontinence related to activity Intolerance and cognitive impairment. Interventions included incontinence: check and change resident every 2-4 hours, cleanse, rinse, dry, and apply a moisture barrier, and instruct resident to call for assistance and report the need to use the bathroom. A care plan note dated 02/09/2024 documented that Resident #158 remained incontinent of bladder and was free of signs and symptoms of urinary tract infection and skin breakdown. Review of the medical record revealed no documented evidence that Resident #158 had a behavior of urinating in their room. On 04/07/2024 at 10:33 AM, Resident #158 was observed in their room resting on the bed during the initial tour. The room was noted to have a strong odor of urine. Underwear was observed hanging in the bathroom. On 04/08/2024 at 10:32 AM, Resident #158's room was observed to have a strong odor of urine, and the bottom sheet on the bed was noted with a large urine stain. Resident #158 was out of bed, sitting on a chair in the room, well-groomed, and eating breakfast. Underwear was observed hanging in the bathroom. On 04/09/2024 at 9:47 AM, a strong urine odor persisted in the resident's room. Resident #158 was observed out of bed sitting in a chair asleep. The floor had been mopped, however there a strong urine odor persisted in the room. On 04/09/2024 at 11:59 AM, Resident # 158 was observed out of bed, sitting on a chair in their room, well-groomed, and their underwear was hanging in the bathroom. The odor of urine is still in the room. On 04/11/2024 at 12:15 PM, Housekeeper #1 stated that the mattress in Resident #158's room had been removed and the room smelled better. On 04/11/2024 at 12:17 PM, observation of Resident #158's room revealed that there was no mattress on the resident's bed, and the room no longer had an odor of urine. Resident #158's underwear was observed hanging in the bathroom. On 04/11/2024 at 11:12 AM, Certified Nursing Assistant #5 was interviewed and stated that Resident #158 is continent but incontinent of urine at times. Certified Nursing Assistant #5 also stated that the urine smell in the room comes from the underwear that the resident hangs in their room as Resident #158 refuses to send their underwear to the laundry. Certified Nursing Assistant #5 further stated that Resident #158 showers every day and washes their underwear in the sink but does not wash it well. On 04/11/2024 at 11:21 AM, Licensed Practical Nurse #1 was interviewed and stated that Resident #158 showers every day and washes their underwear and hangs it in the room. Licensed Practical Nurse #1 also stated that they have changed the mattress and the sheets before, and they did not know where the urine smell was coming from. On 04/11/2024 at 11:49 AM, Housekeeper #1 was interviewed and stated that the smell in Resident #158's the room could be coming from the mattress. Housekeeper #1 also stated that they have changed the mattress a few times, and they think the resident urinates on the mattress, and on the floor at times. On 04/12/2024 at 11:17 AM, Resident # 158 was observed out of bed making their bed. There was no urine odor detected in the resident's room, and Resident #158's underwear was observed hanging in the bathroom. During an interview on 04/12/2024 at 11:17 AM, Licensed Practical Nurse #1 stated that there is no longer a urine odor in Resident #158's room after the housekeeper removed the old mattress and replaced it with a new one. On 04/12/2024 at 10:38 AM, the Director of Nursing was interviewed and stated that that they did not remember if there was a smell in Resident #158's room. The Director of Nursing also stated that they were not aware of the strong smell of urine in the resident room, no-one had informed them about the smell and they were not aware of the issue. 10 NYCRR 415.5(a)

Based on interviews, observations and record reviews conducted during a recertification review (TD8B11), the facility did not ensure that a resident who is unable to carry out activities of daily living received appropriate services to maintain good grooming. This was evident for 1 (Resident #89) of 10 residents reviewed for Activities of Daily Living out of 38 sampled residents. Specifically, Resident #89 was observed with long, untrimmed fingernails that were imbedded with black matter. The findings are: The facility's policy and procedure titled Activities of Daily Living, last reviewed 11/2018, documented that the facility will provide the necessary care and services based on the comprehensive assessment of a resident, including hygiene, such as bathing, dressing, grooming and oral care. Resident #89 was admitted to the facility with diagnoses that included Cerebrovascular Accident, Hemiplegia, and Arthritis. The Activities of Daily Living Care Plan initiated 01/12/2024 documented that the resident required maximum assist of 2 persons for personal hygiene. On 04/08/2024 at 11:57 AM, Resident #89 was observed in bed with long, untrimmed fingernails with black matter underneath each nail. Resident #89 stated that they did not recall the last time anyone trimmed their fingernails and that they were aware their hands and nails were dirty. On 04/12/2024 at 9:15 AM, Resident #89 was again observed in bed with fingernails that were untrimmed and there was black matter under each fingernail. On 04/12/2024 at 9:21 AM, Certified Nursing Assistant #7 was interviewed and stated that they are assigned to Resident #89 most of the time but had not worked with Resident #89 in about two weeks. Certified Nursing Assistant #7 also stated that when they are assigned to Resident #89 they wash the resident every morning and trim their nails when the nails become long or dirty. On 04/12/2024 at 9:30 AM, Registered Nurse Supervisor #1 who was the Charge Nurse on the unit stated that the protocol is to clean each resident's hands before every meal and to clip their fingernails every Sunday. Registered Nurse Supervisor #1 examined Resident #89's hands and stated that it did not appear that the resident's hands had been washed or that their nails had been trimmed as per protocol. Registered Nurse Supervisor #1 further stated that Resident #89 eats with their fingers so this is especially distressing. On 04/12/2024 at 10:46 AM, Certified Nursing Assistant #8 was interviewed and stated that they are a floater currently assigned to Resident #89's on this shift. Certified Nursing Assistant #8 also stated that they served Resident #89 breakfast this morning and used hand sanitizer to clean the resident's hands prior to serving the tray. Resident #89 eats with their fingers and had pancakes with syrup today, so their hands would be sticky after breakfast. Certified Nursing Assistant #8 further stated that the resident's nails are dirty because they scratch themself a lot, and they had not yet given the resident morning care. On 04/12/2024 at 12:36 PM, the Director of Nursing was interviewed and stated that they always foster safe independence in Activities of Daily Living. We hire trained staff and in-service and monitor them regularly to make sure they provide the best care. 10 NYCRR 415.12(a)(3)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure a resident's right to privacy and confidentiality was maintained for 2 (Resident # 48 and Resident # 598) of 39 sampled residents. Specifically, medication blister packs for Resident #48 and Resident #598 were observed on top of a desk in an unlocked room, exposing personal health information. The findings are: The facility policy and procedure titled Confidentiality and Privacy revised 11/2016 documented the facility upholds residents' right to personal privacy and confidentiality for all aspects of care. On 04/08/22 at 10:25 AM, the Regional Environmental Consultant (REC) and State Agent (SA) entered a unlocked Registered Nurse Staff Educator (RNSE) office located on the ground level and accessible to anyone in the facility. Two blister packets of medication were observed in plain view on top of a desk in the RNSE office and the labels containing identifying information for Resident #48 and Resident #598 were visible. Packet #1: Resident # 48's full name, room number, [MEDICATION(S)] Cap 400mg, 1 capsule by mouth three times a day for [CONDITION(S)]. Packet #2: Resident # 598's full name, room number, [MEDICATION(S)] 48.75 mg/195 mg 1 capsule by mouth three times a day related to [CONDITION(S)]. On 04/08/22 at 4:00 PM, the unlocked RNSE office door was opened; and, the medication blister packets for Resident #48 and Resident #598 were observed on a desk. On 04/08/22 at 04:04 PM, the Director of Nursing (DON) was interviewed and stated the RNSE used the blister packs of Resident #48 and Resident #598 as sample medication while conducting facility orientation classes for newly hired nurses. The medication should be stored securely. On 04/11/22 at 10:41 AM, the RNSE was interviewed and stated the blister packs were used as examples during orientation because the RNSE believed the medications were placebos with fake names and labels. The RNSE was unable to secure the medication because they were not given a key for their office door. 415.3 (d)(1)(ii)

Based on staff interviews and record reviews conducted during the recertification survey, the facility did not ensure that all alleged violations involving abuse were reported within a timely manner to the State Survey Agency. This was evident in 1 (Resident #219) out of 7 residents reviewed. Specifically, the facility did not report an allegation of staff-to-resident physical abuse involving Resident #219 to the New York State Department of Health (NYSDOH) immediately but not later than 2 hours of the alleged violation. The findings are: The facility policy titled Reporting and Investigation of Resident Abuse, Neglect, Mistreatment dated 11/2017 documented alleged violations involving mistreatment, neglect, or abuse are reported immediately to the Administrator and to the NYSDOH as required. Resident # 219 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 219 had moderately impaired cognition. The facility's undated Accident/Incident Investigation Summary (AIS) documented Registered Nurse (RN) #1 called Resident #219's Resident Representative (RR) and informed them Resident #219 had a fall on 01/29/2022 at 7:30 AM. After speaking with the resident, the RR called RNS #1 and reported Resident #219 claimed a nurse hit them. The undated AIS documented Certified Nursing Assistant (CNA) #2 wrote a witness statement dated 2/02/2022 that no abuse was observed on 1/29/2022 when Resident #219 fell . The undated AIS documented the facility concluded no abuse occurred citing statements from CNA #1 and CNA #2; therefore, the incident was not reported to the NYSDOH. The undated AIS did not document the date and time the facility became aware of Resident #219's allegation of abuse, when the facility investigation was initiated, and when the investigation concluded. On 04/08/2022 at 12:45 PM, the Director of Nursing (DON) was interviewed and stated RNS #1 made the DON aware Resident #219 alleged they were hit by a nurse. An investigation was initiated and CNA #1, CNA #2, and the nurse were in the room at the time of the incident and denied witnessing abuse. The facility has 2 hours to report an allegation of abuse to the NYSDOH if the facility believed abuse occurred. The DON and Administrator are responsible for reporting alleged abuse. The Administrator was interviewed on 04/11/2022 at 12:13 PM and stated the facility reports abuse to the NYSDOH within 2 hours if a resident incurred injury and within 24 hours if there was no injury. An allegation of abuse does not get reported to the NYSDOH if it is unsubstantiated. The investigation into Resident #219's abuse allegation was unsubstantiated and was not reported to the NYSDOH. 415.4(b)

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure a resident's Minimum Data Set 3.0 (MDS) assessment was transmitted to the Center for Medicare and Medicaid Services (CMS) within 14 days of completion. This was evident for 1 (Resident #2) of 39 residents reviewed. Specifically, the facility did not transmit a quarterly MDS for Resident #2 within 14 days of completion. The findings are: The facility policy titled MDS Assessment revised 10/2020 documented the MDS Department will input the completed MDS into the data systems within 14 days of signing off on a quarterly assessment. The MDS Submission Report dated 04/08/2022 documented the quarterly MDS for Resident #2 was completed on 1/10/2022 and was submitted for transmission on 4/07/2022, more than 14 days after completion. On 04/08/22 at 03:30 PM, the MDS Coordinator (MDSC) was interviewed and stated they were responsible for ensuring completed MDS assessments are submitted for review by a Third Party Application prior to being transmitted to CMS. The MDSC was not aware the quarterly MDS for Resident #2 had not been electronically received by the Third Party Application nor transmitted to CMS. On 04/08/2022 at 03:35 PM, the Regional MDS Coordinator (RMDSC) was interviewed and stated there was a glitch in the facility's computer system that caused Resident #2's MDS submission to go missing. Resident #2's MDS was an isolated case. 415.11(b)

Based on record review and interviews conducted during the Recertification and Abbreviated Complaint survey (NY 436), the facility did not ensure that a resident and/or resident representative (RR) was invited to review the resident's plan of care with the Interdisciplinary Team (IDT). This was evident for 1 (Resident #103) of 39 residents reviewed. Specifically, Resident #103 and their RR were not invited to scheduled quarterly Care Plan Meetings (CPM). The findings are: The facility policy titled Care Planning Process revised 1/2022 documented the Social Worker (SW) invites residents and RRs to scheduled CPMs via phone, in person, or in writing; and, documents the invitation and participation in the medical record. Resident # 103 was diagnosed with [CONDITION(S)], [CONDITION(S)], and [CONDITION(S)]. The quarterly Minimum Data Set 3.0 (MDS) assessments dated 8/7/21 and 11/7/21 documented Resident #103 had moderately impaired cognition with a score of 12 on their Brief Interview for Mental Status (BIMS) assessment. On 6/25/21 at 12:15PM, complainant reported to the Aspen Complaint/Incident Tracking System the facility had not involved complainant in the care planning for Resident #103. On 04/04/2022 at 3:07 PM, Resident #103 was interviewed and stated they had not been invited to attend quarterly CPMs with the IDT. CPM notes and attendance record documented CPMs were held on 8/18/21 and 11/18/21. Signatures of IDT team were documented. There was no documented evidence Resident #103 nor their RR were invited to or attended the quarterly CPMs. On 04/08/22 at 11:31 AM, the SW was interviewed and stated residents with a BIMS score of 12 to 15 are invited to their CPMs. The residents and the RR are invited to initial, annual, and significant change CPMs. The SW does not invite the resident or RR to quarterly CPMs. On 04/11/22 at 10:48 AM, the SW Director (SWD) was interviewed and stated a progress note is written when a resident and/or RR are invited to CPMs and an attendance sheet documents the signatures of who attends the CPMs. Residents and RRs were not invited to quarterly CPMs until the process was changed within the past year. 415.11(c)(2)(i-iii)

Based on observations, record review, and interviews conducted during a Recertification survey, the facility did not ensure that drugs and biologicals were stored in locked compartments. This was evident for for 2 of 39 sampled residents (Resident 348 and #598). Specifically, blister packs of medication for Resident #48 and Resident #598 were observed in an unlocked office two blister packets containing medications were observed on a desk in an unlocked room on the 1st floor in building B. The findings are: The facility policy titled Storage of Medications dated 4/19 documented medication was kept in a securely locked storage area with limited access by authorized personnel. On 04/08/22 at 10:25 AM, the Regional Environmental Consultant (REC) and State Agent (SA) entered a unlocked Registered Nurse Staff Educator (RNSE) office located on the ground level and accessible to anyone in the facility. Two blister packets of medication were observed in plain view on top of a desk in the RNSE office and the labels containing identifying information for Resident #48 and Resident #598 were visible. Packet #1: Resident # 48's full name, room number, [MEDICATION(S)] Cap 400mg, 1 capsule by mouth three times a day for [CONDITION(S)]. Packet #2: Resident # 598's full name, room number, [MEDICATION(S)] 48.75 mg/195 mg 1 capsule by mouth three times a day related to [CONDITION(S)]. On 04/08/22 at 4:00 PM, the unlocked RNSE office door was opened; and, the medication blister packets for Resident #48 and Resident #598 were observed on a desk. On 04/08/22 at 04:04 PM, the Director of Nursing (DON) was interviewed and stated the RNSE used the blister packs of Resident #48 and Resident #598 as sample medication while conducting facility orientation classes for newly hired nurses. The medication should be stored securely. On 04/11/22 at 10:41 AM, the RNSE was interviewed and stated the blister packs were used as examples during orientation because the RNSE believed the medications were placebos with fake names and labels. The RNSE was unable to secure the medication because they were not given a key for their office door. 415.18(d)

Based on observation, record review, and interview conducted during the Recertification survey, the facility did not ensure that a resident with missing dentures was promptly referred for dental evaluation. This was evident for 1 (Resident #189) of 1 residents reviewed out of a sample of 39 residents. Specifically, Resident #189 reported their dentures were missing for 2 months and they were not evaluated by the dentist. The findings are: The facility policy titled Care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Dentures are kept in a labeled cup at night. Resident ##189 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #189 was cognitively intact and had no loosely fitting full or partial dentures. Resident #189 was observed on multiple occasions from 04/05/22 at 10:36 AM through 04/11/2022 at 9:00 AM with partial lower dentures and no upper dentures in their mouth. Resident #189 was interviewed during observation and stated they were told the dentist would evaluate them for replacement of full upper dentures missing for approximately 2 months. The dentist did not evaluate Resident #189 since denture loss. The Comprehensive Care Plan (CCP) related to Dental Health Problems was initiated 8/05/21 and documented the Certified Nursing Assistant (CNA) would assist Resident #189 with performing oral hygiene twice daily. A Dental Consult dated 08/13/21 documented Resident #189 was wearing their full upper denture and had edentulous maxilla and partially edentulous mandible. The CNA Documentation Survey Report dated 3/01/2022 through 4/05/2022 documented Resident #189's assigned CNA signing for presence of full upper dentures per each shift. There was no documented evidence in the medical record Resident #189 was missing full upper dentures or was referred for dental evaluation. On 04/11/22 at 09:36 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated they were unaware Resident #189 was missing their full upper dentures. LPN #1 walked to Resident #189's room during the interview, searched the room, and was verbally informed by the resident upper dentures were missing and they have not seen the dentist. LPN #1 stated the CNA assigned to Resident #189 was changed 2 months ago and there have been unfamiliar CNAs placed on their assignment. The CNAs inform the LPN if there are missing dentures. On 04/11/22 at 12:13 PM, CNA #2 was interviewed and stated CNA assignments are rotated but CNAs are responsible for looking in the medical record to identify residents with dentures. If the dentures are missing, the CNA searches the resident's room and then reports to the LPN. On 04/11/22 at 02:13 PM, The Director of Nursing (DON) was interviewed and stated the CNAs are responsible for reporting missing dentures to the LPN so a dental consult can be arranged. The DON was unable to explain the reason Resident #189 was not referred for dental services. 415.17(a-d)

Based on observations, record reviews, and interviews conducted during the third Focused Infection Control Survey (FICS) and Complaint Investigation Survey (#NY 990) the facility did not ensure necessary maintenance and housekeeping services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, 7 resident rooms were observed with torn upholstery on arm rests and seat covers of chairs, cracked tiles, rusted air conditioner (AC) vent unit cover, broken toilet flushometer, dirty floors, garbage bin overflowing with trash in the bathroom, stained and broken window rails and curtain. This was evident for 1 of 6 units observed (A2 unit). The findings are: The facility Policy titled: Safety in the Environment policy and procedure dated 11/2017 documented that the facility ensures each resident has a safe, clean, comfortable, and home-like environment to receive treatment and support for activities of daily living. The layout of the facility maximizes resident independence and does not pose a safety risk. The purpose is to maintain infection control standards and appropriate housekeeping and maintenance standards for the residents and the units. The Facility policy titled: Privacy Curtains Policy dated 12/18 documented that it is the policy of the facility to change privacy curtains/ window curtains after a resident is discharged , transferred to another room, or when isolation precaution is discontinued. There is no policy or schedule for stripping and cleaning the room as per Building Maintenance Director and the Administrator. On 7/29/2020, from 10:55 AM to 11:25 AM, an observation tour was conducted on the A2 Unit. The following were observed: Room A 201-Had broken tiles on the bathroom walls and floor, floor tiles lifting off of the floor, two broken window rails were covered with tin foil, AC vent unit cover was rusted with missing switch cover, and an accumulation of dirt and debris on the floor. Room A 208- Had two bedside tables with whitish sticky stains, and rough edges, accumulation of dirt and debris on the floor. Two chairs with torn upholstery on the armrest, and the resident's closet knob was broken. Five pieces of a garbage bag were used as a tie to close the closet doors. Room A 209- Had two broken bedside drawers, two resident's clothing cabinet with peeling laminate on the upper corner of the closet with rough edges, a brownish sticky stain on top of the bedside table. There were wheelchair tire marks and an accumulation of dust and debris on the floor. Room A 210-Had two broken bedside drawers, two side tables that have rough edges and brownish sticky stains, broken window hooks hanging on a thin metal conduit pipe by the window, and half of a privacy curtain with brownish stains was observed hanging. Room A 211-Had two broken bedside drawers an accumulation of dirt and debris on the floor, torn upholstery on the seat of the chair, and an accumulation of debris, and brownish sticky stain on the bedside table. Room A 216 -Had two clothing cabinets that have peeling laminate on the upper left corner of cabinet door, a broken toilet flushometer wrapped with a garbage bag between flush connection and spud flange touching residents' toilet lid and toilet bowl, and a garbage bin overflowing with trash in the bathroom. Room A 228 - Had a garbage bin overflowing with trash in the bathroom, and accumulation of dirt and debris on the floor The Maintenance Request Log Sheets dated 7/1/2020 to 7/20/2020 documented that there were no requests for any of the items in need of repair or attention identified by the surveyor. On 07/29/2020, at 2:33 PM, an interview was conducted with the A2 Unit housekeeping staff (HK#3). The HK#3 stated that no matter how much they clean, the movement of residents coming in and out of the unit has been hard to keep up and that she was assigned two units to clean in a day. HK#3 also stated each morning, she cleans the floors and wipes the residents' tables, but at times old debris and stains on the floor are hard to remove and clean. HK#3 further stated she has reported the issue to the supervisor. On 8/12/2020 at 2:04 PM, an interview was conducted with the CNA#3, who was assigned to room A 201, A 208, A 209, and A 211. CNA #3 stated that she is aware if any items in the resident's rooms, including furniture, broken toilets, she is to write it down on the logbook and report the concerns. CNA #3 also stated she did not notice or report any of the issues identified by the surveyor to her supervisor or write it in the maintenance log books. On 8/13/2020 at 1:06 PM, an interview was conducted with the CNA # 4 who was assigned to room # 228. CNA #4 stated that she is aware that if there are any broken items, she is responsible for writing the issues to the maintenance logbook. CNA #4 admitted that she was so busy providing care for the residents that she did not have a chance to check the room and make sure it was clutter-free and clean. On 8/13/2020 at 2:09 PM, an interview was conducted with the CNA #5, who was assigned to room A 209 and A 210. CNA #5 stated that they were informed to log any maintenance issues in the log book but he did not know where on the unit to locate the log book. CNA #5 further stated he had not reported anything to the maintenance department in July 2020. On 7/29/2020 at 11:20 AM, an interview was conducted with a Licensed Practical Nurse (LPN). The LPN stated that she is swamped, providing medication and treatment to residents that she does not have the time to observe the residents' surroundings. On 07/29/2020 at 11:26 PM, an interview was conducted with the Director of Building Services and Maintenance (DBSM). The DBSM stated that the unit was supposed to be renovated but was postponed due to the pandemic. The DBSM also stated the unit should have been maintained in a clean, clutter-free manner and repairs should have been made as necessary. The DBSM further stated that no one reported these issues to him, the concerns were not documented in the log book and he had not done rounds on the unit. On 07/29/2020, at 4:15 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that it is also the nursing staff's responsibility, especially the supervisor, and CNAs to report any issues related to residents' rooms such as cleanliness and broken items. On 8/13/2020 at 2:09 PM, an interview was conducted with the Housekeeping Director (HKD). The HKD stated that they have not thoroughly strip cleaned the unit rooms since they are doing it unit per unit. The HKD also stated that he usually would do daily rounds and address any issues such as cleanliness and maintenance issues. The HKD also stated that each morning, the housekeepers are responsible for emptying garbage bins in each room, wiping the tables and chairs, and sweeping and mopping the floor daily. The Housekeeping staff is aware that if any issues or maintenance concerns arise, Housekeeping and maintenance supervisors can be reached via maintenance logbook, cellphone, calling the security, or via radio. 415.5(h)(2)

Based on observations, interviews, and record reviews conducted during the COVID-19 Focused Infection Control Survey (#NY 990) completed on 8/13/20, the facility did not maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 1(A 2) of 6 units reviewed. Specifically, 1). a Certified Nursing Assistant (CNA) was observed providing care to two residents without performing hand hygiene between residents; 2). Soiled laundry and linen including resident clothing, towels, gowns, blankets and bed sheets were observed piled on the floor in a resident's room; and 3). Linens were observed touching the floor inside the linen closet, two clean linen carts in the hallway uncovered and unattended, and linens touching the hallway walls. The findings are: The Facility policy titled: Hand Hygiene Protocol Policy # IC 800 - C-07 effective 11/2017 documented that all personnel must perform hand hygiene as per standard guidelines to prevent transmission of infection/disease to residents/patients, employees, and visitors. The guidelines for hand hygiene documented that before and after resident contact and when in doubt about the necessity for hand hygiene, personnel are encouraged to wash hands. The Facility Policy titled: Infection Prevention Control Program Policy # IC 800-A-01 effective 4/25/2020 documented nursing services shall maintain the highest level of professional hygiene and follow all policies and procedures related to infection prevention and control, including proper handwashing, transmission-based isolation procedures, and others as outlined in the manual. The policy also documented staff will comply with policy and procedures for the safe handling, storage, and transportation of clean and soiled linens. An undated facility policy titled: Collection and Transport of Soiled Laundry documented that the Certified Nursing Assistants (CNAs) will bag each resident's laundry. The CNAs will place the bag in a designated laundry hamper that is in the soiled utility room. 1. On 7/29/2020 at 11:02 AM, during the observation rounds on unit A 2 CNA #1 was observed dressing Resident #2. CNA #1 exited the room without performing hand hygiene, proceeded to the clean linen cart and removed two sheets and an incontinent pad with bare hands. CNA #1 walked to Resident #3's room holding the clean linens and incontinent pad directly touching her clothing. The CNA placed the linens and incontinent pad on the resident's bed and began to fix the hair of Resident #3. The CNA was not observed wearing gloves or performing hand hygiene between tasks. On 07/29/2020 at 11:05 AM, an interview was conducted with CNA#1. CNA#1 stated that she was so busy that she forgot to wash her hands after dressing Resident #2. The CNA further stated that she forgot to wash her hands prior to entering Resident #3's room and before touching the resident's clothing and hair. The CNA stated that she did not notice that the linens were in contact with her uniform. On 07/29/2020 at 4:32 PM, an interview was conducted with the Infection Control Nurse (ICN). The ICN stated that all unit staff is aware of the strict hand hygiene/hand washing policy and infection control policy. All staff should wash hands before and after providing resident care. 2. On 07/29/2020, between 10:55 AM and 11:25 AM, soiled residents' clothing and linen were observed placed directly on the floor or on chairs in multiple resident rooms and were not stored in a sanitary manner in either plastic bags or hampers. (Rooms # A201, A209, A211, A215, A216, A222, and A228). On 07/29/2020 at 2:35 PM, an interview was conducted with CNA #2, who was assigned to Room A215. CNA #2 stated that she was very busy and did not notice that the resident's clothes and linens were on the floor. CNA #2 also stated that after providing resident care, soiled laundry is placed in a bag and taken to the soiled utility room. On 8/12/2020 at 2:04 PM, an interview was conducted with CNA #3, who was assigned to Room #A201, A209, and A211. CNA #3 stated that she is aware of the laundry and linen policy that all soiled laundry, soiled linens should be placed in a plastic bag and brought to the soiled utility room. CNA #3 also stated that Room #A211 was not her usual assignment, and she forgot to check the room. Room #A201 is her usual assignment, and she knows that there are boxes and soiled clothing on the floor but was unable to remove the soiled laundry and linens because the resident does not allow her to do so. CNA #3 further stated that she was not sure if Room #A209 was assigned to her, so she did not check the room that day. On 08/13/2020 at 1:06 PM, an interview was conducted with the CNA#4, who was assigned to room #A222 and #A228. CNA #4 stated that the resident who resides in room #A222 is independent and mixes clean and soiled laundry in a bag. CNA #4 also stated she did not follow up with the resident after care and did not report the issue to her supervisor. CNA #4 further stated that she was so busy providing care for other residents that she did not have a chance to go back to Room #A228 to make sure there was no laundry or clothing on the floor. On 8/13/2020 at 2:09 PM, an interview was conducted with the Housekeeping Director (HKD). The HKD stated that the laundry staff are assigned to bring all laundry from the soiled utility room to the basement for laundry. It is the CNA's role after each care to place all the soiled laundry and linens in a separate plastic bag and place them inside the yellow bin in the soiled utility room. As per HKD, if the housekeeping or laundry staff saw any of the laundry issues, they should have reported it to the nurse supervisor or to her. 3. On 07/29/2020 at 11AM during tour on Unit A2, a clean linen closet was observed with linens touching the floor. Two linen carts in the hallway between Room #A249 and A248 were also observed uncovered, unattended with linens touching the hallway walls. On 07/29/2020 at 11:03 AM, an interview was conducted with CNA#2. CNA #2 stated clean linen is taken from the linen closet and stored on linen carts each morning before providing resident care. Linen carts should be covered at all times. CNA#2 also stated she does not know who left the cart open and that all carts should be closed and secured without linens touching the floor or walls. On 07/29/2020 at 11:05 AM, an interview was conducted with the Director of Maintenance (DM), who was providing coverage for HKD. The DM stated that linen closet should only consist of clean linens and incontinent pads. The DM also stated linens should not be touching the floor as the linen closet has dust and clutter. 415.19(b)(4),(c)

Based on observation, record review and staff interviews, it was determined that the facility did not supervise a resident during a dinner meal who is totally dependent on staff for eating. Subsequently, the resident spilled a bowl of hot soup on her right thigh and sustained second degree burns. This was evident for 1 of 30 sampled residents (Resident #7) This resulted in actual harm that is not an immediate jeopardy. The finding is: Resident #7 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Comprehensive Episodic Care Plan dated 1/10/2011 documents "... Pushes food from table." The approach/plan of action documented was to "...Monitor behavior Report changes Involve family in care." There were no further interventions documented for this behavior until 10/5/11. The Resident Care Profile Plan/Accountability dated 1/11 to 4/11 did not document that the resident "pushes food from table." The nurses' notes dated 4/22/11 to 10/4/11 did not document any evidence of the resident "pushes food from table." The MDS (Minimal Data Set) 3.0 dated 9/10/2011 documents that the resident has severe cognitive impairment and for eating is totally dependent on one person physical assistance. This MDS further documents that for locomotion on the unit, the resident is totally dependent on one person physical assistance. On 11/10/11 at 10 am, the resident was observed sitting in a gerichair in the dining room asleep. On 11/15/11 at 10 AM, during the dressing change, three burn areas were observed on the resident's right thigh. One burn area measured approximately 3.5 cm (length) x 3.5 cm (centimeters) (width). A second burn area measuring 1.5 cm x 1.5 cm and a third burn area scab measuring 1.5 cm x 1.5 cm. The Resident Care Profile Plan/Accountability (Certified Nursing Assistant Accountability Record) dated 10/11 (initiated 9/30/11) documents that for eating, the resident is totally dependent and requires the assistance of one person. Additionally, this plan documented that the resident does not ambulate and uses a gerichair. This plan documented that the resident's behaviors are resistive to care, physically abusive, yelling, screaming and hitting staff. This plan does not document that the resident has a behavior of grabbing or pushing food off the dining room table. The QA (Quality Assurance Investigation) investigation form dated 10/5/2011 documents "...At about 5:30 PM a tray was placed in front of pt. (patient) with her food. Pt. took the soup bowl and turned it on her thigh...." The nurses' note dated 10/5/11 at 5:30pm documented "Received resident in the dinning room on recliner chair, alert and responsive, but very confused. At about super time, Pt. (patient) reached out and took a bowel of soup and inadvertently spilled it on her thigh, when assessed no redness or visible injury noted at this time. At about 8pm the CNA (Certified Nurse Assistant) called to my attention ADL (Activities of Daily Living) care, blister noted on the right thigh about 4x6x0cm (centimeters). NP (Nurse Practitioner) made aware..." The Comprehensive Episodic Care Plan dated 10/5/11 documents " .........Behavior of grabbing food.....Discourage behavior....Offer pleasure finger foods." The medical note dated 10/6/11 documented "Pt c (with) burn and open blister R (right) thigh 2 (secondary) spilling hot soup..." The medical note dated 10/13/11 documented "ATSP (asked to see patient) for R thigh and open blisters...Skin R thigh c large wound to thigh s/p (status [REDACTED].R side of that blister is small open area 0.6x0.6cm pink..." The "Internal Quality Assurance Document" dated 10/13/11 documented " ... a burn with blisters to her Right thigh subsequent to the resident spilling hot soup on herself during the dinner meal on 10/5/11 ..." This document further stated that "...She is alert and oriented to person only. She is unable to follow simple commands. She is total assist of 2 for all ADL's (activities of daily living), and is spoon fed. She is often restless, grabbing at food or nearby staff..." The Summary Of Incident And Investigation dated 10/13/11 documented "...According to staff interviews, she was seated next to a resident who is able to feed himself, and to whom dinner had been served, and across from a resident who feeds herself and to whom dinner had been served. Staff was in the process of serving dinner trays or feeding other residents. It is unclear whether or not (name of resident) had been served dinner as she is in the habit of grabbing other resident's food and dropping it to the floor. In a statement made by the RN, (name of Registered Nurse) she states she was feeding a resident across the room and saw (name of resident) pick up the bowl of soup. She was unable to reach the resident in time to prevent her from spilling the soup. Other staff report that they were involved in either serving or feeding other residents and became aware of incident only after it had occurred. The RN performed an immediate assessment of the (name of resident) right thigh and noted no redness or injury ... At approximately 8:00p.m. when the resident was being put back to bed, the primary nurses' aide reported that she noted blisters to the resident's thigh, and called (name of RN). The conclusion documented was "... It appears the cause of burn was the spillage of soup and that it was accidental, caused by the resident grabbing at a bowl of soup as was her pattern of behavior..." The medical note dated 10/14/11 documented "Fup (follow up) wounds Pt c Wounds R thigh 2 Burn ... R thigh wounds 1 large wound Open c 100% soft slough 5.2x6.1cm...2 smaller wound c 100% slough soft 2x1.5cm...3 small open wound pink o (no) slough..." On 11/10/11 at 12PM, the unit Registered Nurse manager was interviewed and stated that the resident has behaviors of grabbing other residents' foods but it is not documented on the CNA (Certified Nurse Aide) accountability record. She further stated that the management of resident behaviors should be documented in the care plan and instructions given to CNA's on the CNA accountability record. On 11/15/11 at 9:30AM the Director of Nursing was interviewed and stated that the burn was not reported (to the Department of Health) because it was self inflicted. The Director of Nursing stated that this resident has a behavior of grabbing food. Additionally, the resident's tray should not be placed in front of her until the staff is ready to feed her. She further stated that these interventions should be documented in the care plan and CNA(certified nursing assistant) accountability record. On 11/15/11 at 10:30AM the 3-11PM charge Registered Nurse was interviewed and stated that she did not know who gave the resident a meal tray. The Registered Nurse stated that the plan was to feed her and not seat her with other resident's. However, on the date of the incident, the resident was seated at a table with other residents who feed themselves. On 11/15/11 the assigned CNA on the 3-11PM evening shift was interviewed and stated that "I was assigned to the resident that day (10/5/2011). I would normally feed the resident but ... I was with another resident. I do not know how she was able to get the bowl of soup. She normally would not sit with other resident's because she is known for grabbing..." 415.12(h)(1)(2) 415.12(h)(1)